Short-Scar FaceLift

OperatíueStrategiesand Techniques

tli

EdirOdby
Patrick L.Tonnard o Alexi.sM.Verpaele
Short-ScarFaceLift
Operative Strategiesnnd
Techniaues
Short-ScarFaceLift
nrud.
Operotive Strnteg'ies
Techniques

EDITED BY

PatrickL. Tonnard, MD
A¡sistantClinicalProfcssor,Departmcntof PlasticSurger¡
Gent UniversityHospital;Dircctor, CoupureCcntrum
Voor Plasúschc Chirurgie,Gent, Belgium

AlexisM. Verpaele,MD
AssistantClinicalP¡oiessor,Departmentof PlasticSurger¡
Gent UniversityHospital;Director,CoupureCentrum
Voor Plastische Chi¡urgie,Gent, Bclgium

II,LUSTRATIONS
RY
CamcronSlaydcn,Ms

@
Quality Medical Publishing,Inc.
sT. LOUIS,MISSOUzu
2007
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 To

the chi.ld¡enof Mya¡mar in need of our time end ou¡ skillt

for liberating them from the curseof cleft lip and palate

Pat¡ick L. Tonnard and Aleis M. Verpaele

 Contribwtors

Daniel C. Baker, MD
ProfcssorofSurgcry,l)cpartmellt ofPl¡stic Surgcr¡ lI{RS Ncrv York University,
New York, New york;'fravcling Profcssor,InternationalSocictyofAestlrctic
PlasricSurgcr],

Terrence W Bruner, MD, MBA

lksidcnt, Dir.isiorrofPlast¡cSurgery,llaylor CollcgeofMedicinc, Houston,Tcxas

Alain Fogli, MD
Narior¡l Sccrct¡ryfor Franceof fntern¡tion¡l SocictyofAcsth(ic Plastic
Surgcr¡ Dc¡'rartnrcnt Chitc¡u Bcrgcr,
ofPlastic¡nd AcsthcticSurgcry,CliDiqr.rc
Marscille,francc

Joseph P. Hunstad, MD
Assist¡ntConsukingPlof¡ssor,l)cpartmcntofSurgcr¡ ScctionofPlasticSurger¡
Dukc Mcd¡calCcntcr, Durham;ScctiorrHcad of PlasticSurgcry',Dcpartmcnt
of Sr¡rgcry,CarolinasMcdicalCcnrcr,UnivcrsityHosp¡txl,Charlottc,
North Carolina

Mark Lau¡ence Jewell, MD

AssistantClinicalProf¡ssor,l)ep¡rtnrcnt of PlasticSurgcry,Orcg(nrHc¡lth Scicncc
Univcrsity,Pordlnd, Orcgon

Daniel Labbé, MD
PrivatcPr¡ctice,PrivatcHospitalSt. Martin; PlasricSurgcon,Dep¡rtmcnt ofPlastic
Surgcr¡ CrrcnUniversitvHospital,cacn, FraDcc

Foad Nahai, MD
ltlasticSurgcon,PacesPlasticSurgcr¡ Atlanta,Gcorgia

tulien Nicolas, MD
Departmentof MaxillotácialarrdPlasticSurgerv,AnatomyLalnratory Caen
UnivcrsityHospit.ll,C¡c¡I, ¡rrncc

Thomas L. Roberts III, MD

Adjunct ProfessorofPlasticSurger¡ DcparnncntolSurgery,Medic¡l U,riversity
of South Carolinir,Sprrtanburg,South Carolina
 ThomasL. Roberts ry DMD,MsD
VirginiaCornmonwcalthUnir-ersity
SeniorRcsidcnt,Dcplr¡ncnt of C)rthoclontics,
Schoolof Dcntistr¡ Richnronci,Virginia

Patrick L. Tonnard, MD
AssistantClinicll Prot¡ssor,l)cprrtnrcrrtof PlasticSurger¡ Gent University
Hospital;Director,Coop(rc Ccr)truolV(x)r Plustischc Chirurgie,Gent, Belgium

Alexis M. Verpaele, MD
AssistxntClinicalProf¡ssor',
l)c¡'rlrtnrcnrof PlusticSurgcry,Gent University
Hospitil; Dircctol, Cor.lpurcCcotrum V(x)r PllstischcClrirurgic,GeDt,Belgium

a
 Foreword

lt is nN greet pri\'¡lcgc to Nritc thc fi¡rcrvord firr Drs. l)ltrick T<rn¡rrci ¡nd
Alcris Vcrpaele's ncl lmrk, Sltort-ScarFúce Lill: Optmtit¿ Stratt¡:ri* aul
'lttltúqus,
Valutttc IL'fl¡ts *ork scrvcsirs:r compirrion tcxt to thcir first xrl
u¡rc <¡ntltc MACS Iift, prrblishcclin 2004. In contcrrplirtingwhat to writ.,
thc rlucstionI first:rskcdlas r,r'hy¡ sccondvolumcl lhc anslvcrobviouslylics
in their ricsirc to lc¡rort ¡rcrsonal¡rro¡¡r'css:rs
u'cll ¡s ¡ rcsp()¡)scto hci¡lhtcncd
intcrcstin thesc¡rr<rcrlrrrcs. Short-sc.rrficc lifis.urd rhc ¡vlACS-lifircchniquc
in plrriculirr h¡ve qrt)\v¡ in populirritv ¡¡rtl ¡rc norv rvitlclv irtloptccl bv sr.rr
gc()nspcrfi)rmingfilciil rcjuvcnation.

'lir
rcflcctthe litlcsprcid intcrcstin thcscpr()cc(iurcs, l)rs. Tonn¡rtl ¡nd Vcr-
pirclchalc crpirntlctltlrc sc()pcofthis scc(¡rtlrr¡lurlc tt¡ includen<xr¡rrlvthcir
orvn l¡rprolch ro l.rciirlrcjuvcnation,bLrt.rlsoth¡t r¡fothcr l cll-kntxvn¡t¡thr¡rs
'l'hc
\\,h{)prcsc¡t thcir sholr sclr tircclifi tcchni<¡ucs. ¡'c¡dcris thc l¡cncficirrv
of this broirdcnctlpcrsfcctivc, g,irining, an cnhirnccrlu¡rtlcrstiurrlin¡¡ of thc
MA(lS Iifi ir¡rprolchfirr ficiirl lcjuvcnrtion, wltilc lcrrnin¡1ebour othcr s(rrlii-
c.tl itppro.tch.^s,inclurlin¡lhtcr'.tlSMAScctomr',fir¡¡lll sr¡t¡'SMASdisscction,
'l'hc
lnd plltvsnrl srrsPcnsion. ¡cchnic¡l r'¡¡i¡tions
rcnrPorll lifi [¡r' firsci¡].lcxr',
illlrsrr¡tcclb)'oipcft riulgconsurilizingslrr)rtscirr¡cchniquesthcrclryofL:r thc
fcir(lcfil plcthor¡ ofcltoiccs fir¡ irrrprovingthc rppcit'¡ncc ofthc lging, tircc-
¡ll uith the aclv:rnrl¡:,cs ofshortcf incisi(ns,thc porcntialfirr lessscarlin¡¡,encl
:r t¡rrickcrrccovcrv,'lhcirL¡tho¡s tlso dcvotc rn()rc¡ttcrttion to ircsthcstic¡n¡h-
sis,r4rcntivcstlittcuics,lnrl technicll rcfincnrcntss ith spccielcnr¡rhesis on ¡rl-
ticrrl cvirlurtion¡ncl lros'to \'¡r\,()lrcr.ltivctcch¡i(I¡cs to ¡cco¡rplish the clc-
silcd ¡csthcticoLr¡conrc tirr c.rch¡uticnt.

Ir is intcrcstirtgl() o()tc thirt thcsc ¡rinim¡l incisionproccrlurcsirrc pirrt of .r

his¡rr'ic¡lcontinr¡r¡¡rrcpl'cscnt¡ng thc ongoin¡¡cvclcofinnovatiorrth¡t is svn
onlnrous rvith our s¡rccirltv. Fronr l pcrsonel pcrspcctivc, I fintl thc stucit of
thc firsr l(X) ¡'clrs ot fircc-lifiingtcchniquesir f'.rscirutingsr.rbjcct.Iu thc eirrlr,
l9(X)s,when ficc lifting rv:rslirsr tlcsclibccl,it consistctlof basicLrlll,linritcrlin
cisionitp¡rloacltcs (irsoliginallvclcscribcd b,vJoscphirnrlLcxcr). As ¡1r'crtcr cx
¡rcricncctas rcquirccl,thc incisio¡s tirr thcsc pr'()ccdr¡rcs bccarnelon¡¡cr,cx
tcnding into the lxrst¡rrriculrrrcgi()rr,¡s \\'cll¡s tr¡nscoron¡lh ¡rcross tlrc sc:rlp.
As sc e¡rproech¡ scconclcc¡turv of tircielrcjuvcurtion,sc finclolrrsclvcsin
s()nrc rcspccts rctLlnring to rvherc rvc stirrtecl, urilizing linitecl irncl ¡rrinimal
incisionirltcchrticlucs irsclcsc¡ibed in this tcxt. Not only hasour incision:rlap
pr'oirchto ficial reju\.c¡atiol1 charl!!cd,but alsoour rpploach to rcpositioning
t i c i . t l . l l h r \ r ¡ n r l c r g ¡ r ¡sricn r i l ¡ r ' r c r l c l i n i ¡ iionnt h c . l ( )v c ¡ r ' sl i r l L ¡ r i r q r h c \ \ r ) r _ k
ot,\lit,t .rrd Pclronic. ()rrr inrpror,:riundcrst.rrrriinq ol lici.rl srni lissue.urt
onrr h.rsslrrpcd Iici.rl rcjulcn.rtionrcchniquc\irrro rrh.rt .rc conrrror¡h con
s i ( l c f c (rir r L r l t i P l i (r )nlc) c f ¡ t i ( n sc.( ) r r ¡ j s l i nnq( ) r( ) r r l \ ' ( ) l - s lc( irnr \ c k r ¡ rtci g l r r c n i r . o .
bLrt.rlsooficn li¡-rn.rlsLrLr SIIAS tlissccriorr.rs lell .rs¡rnrcctlLrlcs llr.rf inclLr(ic
'
' rrl ' l . r i , '. 1, ,rl , l i . . c i r ,' | | , , l t l r i . l . r . i

, { s c ¡ ¡ l r c s c c ¡ irn h r ¡ t h¡ r l t h c s cr o l r r r r c sr.h c l ) r n ( l L r l L ul i)rrr r c p o s i t i o r r i ror fgt i

(i.rl l¡t h¡s ¡g,i1ins\\unl.lb¡cl<.rnilrrc ¡r'c norr ¡crr,ilir¡q rorr¡rtl r¡or'c rrirrinr¡lh
i n v . r s i r tcc c h n i r l u c r\ .\ i t h . l g ( ) . rol l l i n r i t i n qr r r o r L r i t i i¡rrvr r li n c r ' c r r s i rI irrut i c n t
s ¡ l t r t v$ i t h r ¡ u tc o r n ¡ r ' o r r r i s i (l r) qL r t ( ( ) r r rlc' h. c n t . t \ c \ ! c l l c n t r c \ L l l ¡ s( 1 c n 1 ( )
\ t r . t l c ! li ) \ l ) r \ . I i r ¡ r ¡ r . r r. rl n
l 1\1t r ¡ . r c l c . r s\ c l l . l st l r c r l l h c rc ( ) r ) t r i l ) L r r i(r))ftsh r s
\ ( ) l r ¡ r r ri cl l u \ t f c l l r . r ¡( ' l ) l i n r ¡ rl c \ L r l ll\h r r r r r ¡ . l l ( r r . ri lr ¡. r l \ r c ¡ r ' ¡ n er c, l l rl r c o b
l r i r e ( i t l l | ( ) u g , h\..rr f i c 1 (\ ) ls u f u i ( . r. lr r r (r1r ( ) r r s u f c i a . \rl r) l ) f t r . r e l trcr lsr,i e hr ro l l i i l l
\vncflt\.

I r r o L r l i k c l ( ) ( ( ) n q r . r r u l . rlt)cr ' s . l ¡ ¡ r ¡ t ¡ r r lr n ¡ \ ' e f | . r c l c( n t l l r c i f s i q n i l i . . l t r

( ( ) n r r l ) U t i ( ) r ( ) I h c Í i c l ( lo l l i c i . r lI c j r r c r . r r i o r r , r r ricl ri c ¡ i f i c . r l hr h i s c r e c l l c n r
r ( ) r r r l ) r l l t i ( )( n
) l i n n ( \ ¡ l i \ c ¡ p l ) r o . l . h r \r o l i c i . r l. r g , i r r gS.L I I q c o r st ¡ ¡ l . r r h ¡ v c
n r U l l i l ) l e . r I p f ( ) x c l rt o c se h ¡ x ¡ s cl i r ¡ r r rl i r I i n r 1 r | o r i r rtgl r,c l i c i l l . r P l ¡ e u r ' ¡ nocfc'
l h c r f l ) ¡ t i c n t \ :l l r c 5 cs r ¡ f r . l r al c. lcl l r r i q r c s . r r rc( (l ) \ n r e t itcf c . r r n r c n st sl r , u c¡ c o n r
¡ r r ( ) ¡rr. l ( ) .{r)l l c r r h . r r r c i rl ri cq i . r lc o r r l o u r ' r r h i l rcr r i r i r r r i z i r tr hg c r i s i l r l cs i C ¡ t r ¡ l
s L r r g i c .i rol f l c c l i o r r . . \ l l s u I c i c . rllc ( h ¡ r i ( l u c h \ . \ c . r t i r . r r r t ¡ r t ccsl i.s . r t l r , r r t . r c t . .
.ulrl I r r r r i I . r t i o r
\ l
V s l
. l . r i : i n r p o l t . r r irst r ¡ rr t . r r ' l i r ¡ L r s (c)tri rr h c q ( ) , r lttl r c s L r r q i c l l
t
s ( ) l U l i ( )nnr u s lr e n r . r i sn u h s c r \ i c ntl( ) l h c i r c s t h c l i(cl c s t i r ) i r l i ( )( ri (rx, ) ( l\ U f q c ( ) t r \
. . r r rg c t g ( r ' ( l f c \ u l t \ r h ¡ ) u q h . l \ ¡ f i c t \ ( ) 1. l p l ) r ( ) . r c l r c sl o. r sr g . r st l r c r ci \ ] n U r l
t l c l s t . r | r L l i¡rrrfrh] ¡ r r rt ¡ r r ' . r | rr h c r . c l 1 | r i q ü c . l c . ( ) rq( l li ( ) t h c . r e s t l r e t ni ec c t l s , r l
t h c l ) . l l i t r r t .l r ¡ r . r ' J t h i s . r i r ) rl .h i s l ' ( x ) l (o l L : ¡ sr r l r r l e o l t s . ( ) n l n i l l clr{l) e \ c c l
l c n c ci r l l i c i ¡ l r c j L r \ e n x 1 i (n' rn. r r v . r l l c n r , r r i \t c{ 'sh c l ¡ t l r c n rr c r r c lrrl l c i f . r c s t h ! ,
rc 1t().rl\.

J¡nrc$ M. Stuzin, ]\ll)

 Prefnce

l'his sccorlclvoluntcort shorf sclr fr.tcc Iif-tingconrcsjust 3 r'clrs rticr thc pLrb-
lic¡tion of <;ur dcbul loluruc on thc MA(lS-litt shor-r-sc¡r rhltidcctontr'. i¡
th.lt short intcr\':rl,¡he intcrcstin lcss-inr'¡sivc ¡ppro.lchcsto firciirlrejurcnir
ti()n hls gr()\rncrp()rrcnti.rlly
with nr¡nv ncw.rnclcrci¡irrericvckr¡rnrcnts lrcint
rcl)()rtcdbv c\pcrt surgcoosthrouqho(rtthc \\trlcl. lhis ncw tr<xrksecksto
builclon fhirt in¡crcst¡ncl l() cilptufcthc conrritrutionsol othcr sursconss h<r
sllivc our bclicfi¡ slrort sclr'licc lifiing.

_lllt¡s
this volunrc nr.lr bc yicwcd.ls.r c()nl)il¡i()n t() thc fiñt. It hirsits orrn
runirlucchrr|uctcristics ¡nrj.rcjr¡nccslhc cr)necl)ls ¡n(l tcchniqucsr.liscL¡ssctl crr
licr trr ¡ ncrv Iclcl of r¡ndcrst¡nding.Whirt h.rsl¡cc¡r¡lc clc¡r i¡t \rfititl$ tltis
lxxrk is th¡t thc ,\lA(lS liti tcchnit¡ucrcnr¡ins.rsbcncfici¡l ¡nrl rclclirnt rs ir
w¡s ultcn rrc fi¡st rlcscribcrlir in 2002, ¡nrl wc c()nriurrcro fLlllt'cnclorsc irll of'
thc IriDciplcsdcvclopcdin lhc hrst r()lr¡mc.Adtlitionrtllv.rh¡nl(sl() inrcritcti()n
with c()llcrg,r¡cs \'(rldwirlc (ludng n).lor intcfl¡li(u¡l n)ccting,s, \!c hirlc cr¡trc
¡o rccoqnizcrh.rl nr.rrv sulgc()ns'idc.rs ¡bout thc c()t)ccl)t()ffiei¡l rcjuvcnir
'l
tir¡r ¡ni tlrc \'.rvs t() irchic!c it rcrrl to conrcr¡tc. llc tr'c¡tls irr fircc lifiing
scc¡rtt() ii)cus(nr r()hrnlcrcst(n.lti()n,
\'cr-ticlllcctorri,linritineconr¡rlicrrtions.rnd
ticc liti srignrrrr,sh(r-tcning, ck¡r'ntinrc,in(l ()lnin)irinqthc lisli./lrcnciitrirtio.
Furthcrnror-c, it lus ircct¡rrccvidcnl lh¡t thc c{)r¡bin¡tir)nof tlitLrrcrrtsinr1rlc
ln(l cfli'clirc sur!¡ic¡lllnd norrsürqic¡l.¡¡rr'orehcssccnlsto sr¡'k slncrg,istic¡llr
t() (lcl¡cr x rcsnl¡lh.l1is nr(nc thirntllc sunl ()f tltc c(nlrril)Lltitrla
iilct(n's.

\Vc rc¡r¡in c(nt!incc(l()f thc ncccssilr'of l p¡licnt'(r'icntcd .rp¡rlolchro lici.rl

rcjuvcn¡tir)n,p:r1ingckrsc.ltlcnti{)nl() thc p.¡¡icnr'sirrtlivicltrirl rrccclsirrrr.l
.rg
(nr
ing prttcrns.Wc nrust rnovc ¡\'irl fi(¡n ¡ rcliilltcc il stillciirLlrccipc fi)r fil
ciil rcju\cn¡tion. \Vc nol h.rlc tor¡lsth.¡¡;rlk^r Lrst() "rrc¡t" fitticnts fi()t)titlic
.30to ovcr ll0 ti¡lr rrrt¡-csr¡Lrflctv ¡nd flcxibilirvr¡¡hcr th¡¡ rchin!¡ ()n tllc trir
clitir¡n¡lrcflcr olj"ficc lili Plusuppcr Lrlc¡rhlroplirstt'."IlotulinLrnrtoxin, lillcrs,
non¡blittir'cplrotorcjuvcnetion.retlioticc¡ucno,rrnclolhcl nons!¡rgic¡llcch-
niqucsotli'r intclcsrinq(4)ri{)nsti)r rcfining otrr'¡ppfo¡ch to ficirrllgilg. Al
th()ugh irll ol drcsc tcchniqrrcsh;rrr tcnrporirlv¡rrcl li¡ritccl rcsults,thcl rrc
erlrrmouslr'.rp¡rc.rlirrg to thc public lTccirusc of their nti¡ri¡¡¡l downtinlc rvith
rcduccrlconrplic.rtions. I! is thcreli)rcinrper'.rtivc
lin Lrsto linrit thc clorvnsirlc
of oper¡tilc procc(luresrr'hilc¡rlcsclvingtlrcir v itlitv rhrough cilictivc encl
k¡r!¡ st.rntlinqrcsrrlts.()Lrvioush,tlrc ()!rlcor)tcof-.r rcjtrer.rtint tre¡tn¡ct1tts
nol solclv tcchniqLrcclcpcndcnt.(irrr'cct pr'c<4rcrativc ircsthetic¿nillrsisis the
l(c\'[o dc!cnnininq the bcsr tcchniqLrcs fbf ¡chic\.ingtl]c dcsifcdlcsuit.
Wc believc that thcse two volt¡nrcs c<¡rt¡i¡ r'alu¡ble infbn¡atio¡ firr irrrv sL¡r-
gcor involved in fircial rcjuvcnirtion. Slrort scar ficc lifiing is ¡ conccpt thirt is
rirpicllvgeining populoitv im(nli f:1ciilacsthcticsurgeons,¡ncl l,l'rich is rn
nccd of in-depth ¡¡ill,vsis .urd dct,rilccl tcrchirg. HopefiLllv thcsc brxrks u,ill
hclp to Ioü,er the th¡csl'roldtirl pcrfbrming rrinirnallv invlsive flcc-lit'r surgcrv
fi)r voLLng,incxpcriclccrl sulgcons rvhilc provicling technical pc:trls irtrd io
sights to cxperienceclsurgcons !\1r) ¡rc irccustomcdto thcir estirl¡lishcrltcclr'
nitlucs. Corresponclcnccfi()n) ()Lr collc¡gucs rcports shorte¡rcd d<xvntinrcs,
improvecl natural rcsülts, ¡ncl crrh¡nccd plcirsurc in opereting illicr iral(lpritrg
so¡nc or :rll of thc conccpts ()f thc MACS lift and other slror¡-scirl ficc-lifr
tcclrn'qucs.lt is or.rrho¡rcto corrvcvsomc ofthis enthusi¡sr¡to our rctclcrs.

Vrlumc II is ¡ nrulti¡utlror\\rn'k rlith contriLrutionsfionr cnrincnt pllstic slrr'-

gcoDsdcciicirtcd to this liclclofwork.-fhc tiDrcwas r\re fbr bringiug tog$hcr'
thc icles ofclifl-c¡clttcxpcrtswl)(),dlth()ughthcy h:rvevlriorrsvict¡oinrs lncl
r¡r¡rroirchcs,
lrc ill dlinkiog in thc silrllcdirccti(n.

'l
hc L¡ookis divideclinto tw() pil¡'rs.ln thc first ¡rirrt,rhc sr.rtrjccofshort-sclr fircc
lifiing is rppro:rchcrlfirrnr cliflcrcnt iurglcs.rrVclrcgin rvith a chirptcr rnt thc p(^v-
cr ot short-scarfhcc liliing in u,hich rvc nlikc thc cirscf¡)r this i¡ppro.ch r{) firc¡irl
rcjuvcnetiorrirnclcx¡rl¡in thc rltionirlc bchinti thc short-sclr fircclifi-rvhv this ¡s
no¡ nrcrclv¡ ficc lifi rvith . sh()r'tscrr. ^-c\t l)r'. Ford Nrlni plovidcs his pcrspcc-
tive i¡¡rdirpp()ach to thc short'scrr fircclifi. l)r ving ol his lotrg-srutlillg cr¡rc
ricncc sith l rrricn' of tcchnic¡ucsfirr fici¡l rcjuvcn¡tiur, hc idcntilics spccihc
sitr¡¡ti(nrs in which ir ¡nininr¡lh'invirsilc irppr()¡chis :rppropiitc .r¡cicliclctivc.

'l'hc
ncxt thrcc chlptersfirus (ln rhc MA(lS lili tcchnitlLrc. In Ohirpter3, l)r.
JoscphHunstcclrcl¡ys his pcrson¡l cxpcricnccrvith thc MAOS-liÍt r4rcrrrtion
irtrclcxpl:rins how sftott'scirr rhyticlcctortrvcin cxp¡nd onc's f:lcc lift prircticc
whilc improving p¡ticnr sirrisf¡cti()n. In Ohl¡rter'4, *e rcvicw rhc irrp(r't¡nt
Icsst¡rslcrrncclcluri¡rg7 ycrrrsofMAOS litiing, inc|.rdingu r.rpdltcoo c(¡Dpu-
cirti(lns,problcms,linritltions,:rnclrcchnicirltips arrdtricks.Thc bionrcch¡¡ics
of thc MACS-lifi tcchniquc is ir,.iclrcssccl in OhLrptcr5 bv Dr. M.rrk Jcrvellrvho
c(mrp¡rcs sutur€ slrspcrlsiontcchniqucs Nith SIVAS flep clcvltiorr irppr()ichcs.
'l'his
clr:rptcrpror iclcsthc rc¡clcr $ith v¡lu.rblc rips on horv to succcctll'ith thc
MACS lili tcchnique. Dr l)¡nicl Birkcr, ir ¡rionecr in short-scarfircc lifiirr¡¡ firr'
thc hst nvo dccacles.clescritrcs I'ris¡rcrsonaltcchniquc ofSrVASecronrvin Ohirp-
tcr'ó, lralancing it \\'itl'r othcr conrpirrlblc irncl convcrgcnt tcchniqucs. ()rrc oi
his kcy mcssegesis thit sut[¡rc tcchniqucs rp¡rlied fbr sculpturing sLtbcutr¡r]c()L¡!i
tissucsirrc ¡s efl¿ctivc xs tr¡diti( ¡l SMAS flrp ullclcrmining tcchniqucs.

l)ert II fircuseson the vadousslncrgisticproccdurcsthat conrbirreto ¡rrodLtcc

exccptidr¡l results.lt bcgiuswith thc work <¡fl)¡s. D¡riel Llbbé LrnclJulicn
Nicol¡s in the ¡n¡tor¡y latrth:1tintcrcstingll,rcvcals
thc anetomicb¡sisofrrrirr-
imilly in\'¡sileneckco¡rccti()nby pl¿tysnr¡suspcnsi(n,bxseclon thc thcorv ()f'
 f¡ci.rt¡

gliding plencsin thc:rging ofthc ncck. 1he clisscctions ¡re e\tcnsivch cie
scribed,.rndthe inll)orr¡nt clinicll inrpLicltionserc pointctl out.

Ncrt l)r'. Al¡ir liogli describeshis sinrplc:rntlsafi tcchliquc firr:tcmporal lilt

irli Lrytisci¡pcrv.Hls techniqueis e l clconrc¡ddition to thc tr{A(ls lif-t,conr
plcting thc tirciallcjur.cnirtionin thc sLrpeliortlrirclol thc ficc, lfiich rvc pcr
sonllli'.r¡rpli in .r slighth nrodihcdlclsion. ()ul pclsonirle\pcricucc\\'ith fhe
shor'tsc:rr'terlpor:rl Iifi is descriLretl
in Ohlptcr 9. Thc book conchrdcstith ¡
chirptcrbl l)f. l horrrrsl{oberrsIll :Lndcollc.r¡¡ucs lho rliscusshol firci¡1r-c
juvcnirtion¡csLrltsc¡r L)c{)ptirrrizcLl lhen spccilicprocc,:lurcs, such irs fici¡l
scLrlptingr.ith nricr'otlt grirfting,ficirrl liposuction,lescr rcsrrrl.rcin.r.:,, l:Ltcr':Ll
cilnth:tlsLlspcnsi(D, ¡LndsuLrnes¡l lip litt, ¡rc rrscrlstncrgistic.rllIrvith cl:rssic:Ll
_fhc
ol short sc¡r ficc'liliing tcclrniqucs. .ruth<¡-s
txsc thcir-tr-c¿tmcrrt orr it rre
t¡ilcrl ¡n¡llsis offr¡ci¡l Lrc¡rn'rrrrrltrcirl .rging.

Si¡ril¡r to thc flrst rolrr¡c. ¡his \r()fl(is c(nrccivcLl

¡s ir lcchnicillguidc ol prlt
ticrl valuc this ¡iIlrc Lr¡sc(l()n thc c\pcricrrccoftlifl.lrcnt cxpcrts.Althouch
\!c h¡\rc irlfcnrl)tcLito ¡rrxidc l consistcnffirrnrlt drr'oLrghout thc Lr<xrk,r\'c
l,crc ciucfi¡lto rcspcctfhc indivi(lLrrlstvlcsr¡l oul cr¡ntributorsto cn¡Lrlcthcnr
¡o ¡.lclir,cr fl-cclr'.l',rrchchlptcr conl¡ins l lisl of sur¡r,ical
¡hcir'nrcss¡rr.cs ¡crr-ls
¡h¡t p()irrt()ut iD ir coneisc,ptr$'crfirlnri]|rrcrthc csscncc(>lc¡ch rrrth0r'scon
¡r'iLrLr¡ion.An¡plc clirric;rloiirnrplcsrrc inclu,lcrlthr()ush()Lrtto illtrstr-¡tcthc
clinic¡l lirlLrcof ¡hc rvor'l<
Ircscntccl.
'l
OrrÍ firsLr rrlLrnrc, lr M A()S-l,ili Sbrrt-St:orllh|,tilt:t:taw\,, \ ¡s corccivc¡.i¡s ¡
clirricirl.rtlirs,guiclingrhc rcrldcfthr()u!,hrhc Lrrsics ofthc tcchni,:1Lrc, rn,.1tlv
ing to proviclc ir conrprchcnsivcundcrst.rnrling, (Jf thc ,Mr\(lS lifr corrccpt.
'l
llis scconclvolun¡cis thc nirf!rrirlcv()luti()nof rhc liIst, lntl is nrcrIlt t0 br-irg
thc rc¡11crrlllo h¡s crrrLrrirccd this conccpl t(r thc nc\t lclcl ol'unrlclsrentlir'.o.
It will ¡lso prolirlc.rnv sur'¡lconinvolvcrl in ticiri lcjtrrcrtirtiorrwilh iru u,'
prcccclcntccl rvcllrh ol"'blclistrrgc" tips lnrl tricks,.rslll thc contribrrtingittr
thors hirlc qivcn thc l¡cstof-rhc¡nsclvcs ro ¡ssistthc rc¡dcr-in his or-hcr-qucst
lirr srrlrcriorrcsultsrnrl grcetcrPeticntslrisl'.rction. Although c¡ch r'olurrrcc¡n
st¡¡rd¡lo¡e, lhcv ¡fc plinncd l() \\'(rli h.rn(i'in-h.rntl, lntl on scvcr-rlocclsions
thclc;uc r-cfclcnccs t'iom thc sccondvolullle to thc fitsl. T() cornl)lcnrcnfthc
nrirlcriirlprcscntcdin this voluruc,\.c fr¡rlcinc[rrlctl¡LvirlcodenroDst|ittirrg r4r
cf.rti\c fcchnicluc¡s Ncll ¡s drc cxPcrtln:rtomicclisscctioDs of I)r'. L¡t¡t¡ó.

'l
lrisseconclvolrLnrc,sirril.rrto drc lirst,rv.rsconccivcrlfionr thc pclccircd nc
cessitvf-of n¡tLrf¡1,s¡f¿, ul1c()l]rplic¡tedj .inclÍcProcluciblcf.rcirl rcjuvcnrti()n
fcchniqllcs¡ncl thc hck ()f strLlctulcdtcachin!¡iD this n iLttel-. lt is orrr prcr
tcrunclhope .rnd,-lesire th¡t this lork rvill continucro stimuhtc thinliing ¡bout
ticiLrl;rgi¡g ¡ntl its trc¡trut'nt in .rn opcn-nrindcrl\'r\','lnLl thrt oLrrpilticnts
*ill L¡ethe ultinr¡tc l)encficiilrics ol-drisclirl()grLc.

tL
Acknowledgments
Writirrg:rbcxrkis ¡ coll¡bor¡rti!ccflir.t, \!ith nür.¡crouspcoplecontritrutingto
rhe firr¡l ¡esult.Thus wc h¡vc nrirny i¡rlivirlLr¡ls¡r thank rvho hirvc assistedus ilr
n)irkillg dris scconclvolr¡mc ¡ rc¡litv. First, rvc rvould Iikc to cx¡rrcssour lpprcei
dtiur to .rllofthe ilurhr¡swlt<¡hlvc contr.ibutcrl fo thist,ork. We ¡skcdthcn Dc-
crusc(f thcil c\pcrtiscill sh()f!-sciffilcclifiirrg,rccognizingth¡t thcsc\\'erein
diviclu¡lsl,hosc schcdrrlcs l crc irlrcird_vfull rvith lcctur.ing lbout thcir tcchni(luc
lDd publishingrhcir irlc¡s.Wc l<non'tlt¡t<)Urrcqucsfro c()ntributcto this book
with thc short cicirrllincsinrposccl\vils¡n c\t¡.irlrurdcn l¡itl ()11thcir shoulclcrc.
Fl¡chofthcir colltribLlti()us is (¡ni(lLrc
¡tr(l \\'ill lrc cxtl.clrrclv
r'¡luablcto thc rc:rd
cr oi this scconrlr'olLrntco¡t shrxt-sciulitcclifiing; thc rcrv trcstofc¡clr ¡uthor,s
knorvlcclsch¡s [)ccnpfcscntcdhcrc. Wc ¡rc r'cff pr()Lrdr¡f this, irnd wc grcith,
.rppfcci¡tcthc gcnUiI]cfiicrrdshil) ()frhcscc\pcrrs.

Sccond.oul th.utks!¡()t() Iirrcn llcrqcr¡nd thc tcrnr ¡r ei\ll'. l ho h.lc r'olkcd

\\'ith us uDdcrr.crvtight dc.rrllincs l{) cls rc thirt this public:rtionis thc bcsr ir
'lhcir
c¡n l)c. c\pertisctnLl rcs¡r(}rrsir'crrcss
is lrol\. irfprcciirtcd.As I putrlishcr.
I(rlcn is ¡n r¡nqucsri(rlcdlc.rdcfin lr()\'idinq l(4r qu¡lirv ntctlicirlprrblic.rtions,
cs|cci:rlllin lhc ficl(lofPl.rsricsur.gcrr'.
Our rrrrrkinl¡rcl¡ri(¡rshiphm.rlrr'¡r,.I)cc¡t
crrjor'.tblc.ucl K¡rcn'scolchinr:ll¡s trccnilrr'¡lu¡trlc.

'l'hirt1,
rvc ¡irkcthis r¡rportLrnirvto c\l)rcss()ur grc.lt ¡ppl.cci:lti()¡r
t() irll ()f ()ur
sr.lfl:()r¡r sccrct.¡fics,(i)onv Hcuqcns.l-is.rVirrrrlcrhecghcn, l.lllcn\¡crclorrcr,
.rntlour nurscs,(ihris¡cllcWt¡ll.rc¡.r, ¡_clc\t'rsijpt,.rnd Kint L¡r()v,ilrc irl.cpl¡c
.rblc in t:rking\v()rk()L¡t()l ()(¡rh.rnclslnd srrpportinqus in c.r'ervpr.ojcct,tlc
spi!c incfc¡scdrr,t)fkloeds ol plcssingdc.rcllir)cr.
Wc ilrc vcfr ti)rtun¡rc !() \\'()rk
rvi¡h streh.r¡ cn¡hLrsixslia tc¡nt.

Fottrrlt,rrc wirot t() c\l)rcss()ut r¿riritltdcf() ()uf p:rtic¡lstvlto hevc gmciorrslv

cotrscrtrccl
to thc publicrrionofthcir ¡rhotogr.ir¡rhs. Wc rcllizc ir is h¡rrlcrro ¡grec
()f i1p(ntfilir lltirnx piclurcrf ir borlt'plrr. ( )ur * ork rvorrld¡or
to thc pL¡L)licirri()tl
lt p<¡ssiblcrvidrt¡r¡tllcir c(x4rcfilti(n.

Finirllt'.rvc tlnr to thirnk oLrl fintilics,r'ho hirlc irl*lys sul.rpa¡.tcd

rrs.lvc irc
¡lso gr'¡tcfillto ¡ll of'rllc c()llcitqucswc h¡vc mct lll ovcf thc \\()rld who hdve
shrfcd thcif a()nlucntslnd critiqucsof our s,olk; thcir iltput h¡s srimrLl¿tcd
!ls t() t'¡rthcr cl¡l)()riltc()uf rcchni(luclncl thc wav $.c .rrctcirchineit.

Patrick L. ToDn¡rd, Mt)

Alexis M. Ver.paclc,un
 Contents

Pfrrt I
Short-Scar Face-Lift Techniques

QbaPtar)
The Power of the Short-ScarVe¡tical FaceLift 3
Patrick L. Tonnard . Al€xis M. V€rpa€l€

CbePter2
Short-Scar
FaceLift:
IndicationsandTechnicalConsiderations45
toad Nanal

Chelter 3
A Systematic
Approachto MACS-Lift OperativeTechniques 75
JoscphP,Hunstd

Choltal 4
Refiningthe MACS-Lift Techniqueand Defining Its Limits l15
PatrickL. Tonnard . AlexisM. Verp¡ele

Chelral 5
The MACS-LiftShort-Scar
FaceLift:
Technical
andStrategic
ConsiderationsI83
MaIk Laur€ncc t€w€U

Cha?teró
Short-Scar Face Lift: Evolution and Applications 207
DanielC. Baker
xvl

Part II
Combined Approaches and Synergistic Procedures

Cbal,tef 7
The AnatomicBasisofPlatysmaSuspcnsJ.on237
Dánicll¡bbé . lulien ñcola¡

Cba.ptar
8
Temporalüft by Fasciapery 271
Alain Fogli

Chúpw9
Combining thc MACS-üft With the Temporal Lift 295
AlexbM, Vclpaclc. PatrickL. Tonnard

Chepr.l l0
The Syncrgyof Multimodal FacialRcjuvcnation:
Putting It All Togeücr 331
ThomesL. Pobcrt¡ II¡ . Tc¡rcnccW. Bruncr . Thor¡a¡ L. RobertsIV

Index 421
Short-ScarFaceLift
Operatfue
Snategies
and
Techniawes
Short-Scar
Face-Lift
Techniques
The Powerof the
Short-Scar
Vertical
FaceLift
Prtrick1,.Tonnirrd . AlcxisM. Vcrpaclc
r{

4 Shor¡ sc.r¡I.rcc l-iti ltchrq!es

T
l¡ is rrnr¡rk¡L.lr Lr.'rvint¡ 'JucinÉ drc tr¡L{(lS lift short scerrhytidcctomy into
our practicc haslo\vcrcd thc thrcshold fir¡ surgicalfirciiúrcju\,cnrti(D. Although
thc tcrm/¿rl lif h:rs¡ r¿thcr ncgrtivc connot:rti()n in Bclllir.rm) rd to ¿ lcsscr:
dcgrcc in F,uropc,thc public emblececlthc reduccdrisk irnd ruortridi¡ ofthc
N{ACS lilt. lr lclclitio|, the reducedstillrnatiand vert,nitur¡l results¡re nol
olly sclf cvidc¡t llrt iuc bci¡g sprcxd L¡vlvord of mouth. ln ¡ cc¡untty rvheLc
rncrlical¡rutrliciwis virturll_vprohibitccl,this is thc most im¡rortut publicirv
channcl. \Yc arc surpriscd horv u'cll known thc tcrn M,4C.! lfl has bccomc as
rulr>rc¡nrl morc pirticnts s¡rccificirllv¡sk fi>r this procctlurc. Paticnts ir¡c rc
ftrrctl trv fiicnds or filuilv nrcIrlbcrs\,r'hoarc cnthusirstic ¡bout thc Lrcal lncs
thesi¡,thc (lr¡ickrccovcr,v, rnrl ¡rrirrlrill,the ¡bscrce o1¡ "iice-lified" look.

It sccnrslogicalth¡r thc nlorc invasivcand ¡¡tlicirlir fircclif-t¡rroccrlurcis, tltc

nroLcrlnnratic dnd l()l1glirstil!¡ thc cfl'cctwrlul..1 l¡c. This is tnrc t() i ccrtilil)
¡roint, bcvoltl u,hich cxtcntling thc irrr,itsilcrtcss ()fthc surg,cr)n1¡),irrcfc:lsc
thc lisk of conrplic:rrions lucl vicld :tn Lrnnrturirlrcsult,with (nly d fi¡rg,in¡l
glin in |cjrrvcnltivcctfcct. lt h¡s trcconrcclc¡r thirt nrorc conrplcr lnd risl<l
'fhc
¡Troccclurcsirrc 11()t ir grrill¡lrtccfif long,cvit¡, of |csrrlts. t\\'ilr stud),cirfricd
()ut bv ll¡kcf li()n) 199(rto 2(XXrh¡s shor'¡r!cf\.(()rrpilriblc rcsultsbctwccr')
t l t ( n t , ' r ' c . l n Jl e r r i l l r . r . i r el r ' , ) ( ( J u t c \ .

Mininrrlly invrsivcproccdnrcslrc !i¡i11in€t in p<4rLrlitliri,

irt irll sLrrgic.rl
ficlds.At
(11ccnd ()lthc spcctr!r'r') \vc scci trcnrcrlctrusbtx¡n in sc¡rlcssficiill rcjLrvcrr¡-
ti(n1 ¡cchnicl!rcs, incluclingrrclioficc¡t¡cncy tcchnicl!rcs,thc so-cirllccl1zr¡12¿d-
túrc i ttr¡¡rrt¡nN, ilod th()sc th¡t osc nooilL)l¡!ivcli!¡h! irlcl lilscr clcviccs.
Thcsc dcviccs¡r'c vcrl, hclvilv nrirrkctccl ¡nd iuc vcfv ¡ppcirlingbcclLrscof thc
inlnlcdi¡tc ctl¡cf ilnd fcduccclckxv¡ tinlc. \_c!crlhclcss.n()nc()lithcnris cilpir
'lhc
blc of rcpltxlucing thc tlLrllitl, and longcvit\,of a tflditir)n¡l ficc lifi.
MA(lS-lifi lits wcll bcnvccn lhcsc t$() cxtrcnrcsof tllc invrsilcncssspcctrlrm
l¡ccirL¡scit rniurirgcs to rc(l!rcc!io\\lrtinrc rnd nrorbidity,rvhilc prcscrvingthc
in(l slirl)ilin,()f !hc rcsull.
cl|l|rli1y
 The Power ofthe Short-ScarV.rtic¿l Facc Liñ

A scaris the hallma¡k ofa surgical interveotion and is the¡efore unwanted by

tlte patient. Even in the bcst hands, in ideal circumstances,and with perfect
tissuc quality, a scar is u¡desi¡ablc and cvcntually impossible to c¡asc.There-
fore shortening üe sc¿rmust be a goal in it¡e[ bút without compromising
the quality and longeüty ofthe rcsuls.

We found that in most caseswe can obtain a very satis$ing result without ex-
tending the sca¡behind üe ear or into the temporal hair. lnitiall¡ we thought
that a short oca¡would only bc possiblein youngerpatients(40 to 50 years),
but with experienceit becameobvious that thc MACS-lift was also lcwalding
for patients in thci¡ sixties and sevcnties,depending on thc quality of their
skin. Thcre arc situations, however, in which tltc cxtcnt of the deformity rc-
quires additional efforts, sornctimcsrcsulting in a longc¡ scar.In thcse excep-
tional casesa long scaris legitimatc becauseit is unavoidable.

It is rcmarkable that after approximately a cenrury of facial rcjuvenation sur-

gery therc is still debateabout the mechanismof facialaging.The processis
most likcly attributable to severalsprcrgistic factors, which explainswhy com-
bining differcnt approaches(for cxamplc, lifting together with filüng proce-
durcs) oftcn dclivcrs superior rcsults, Wc arc surc ofone thingi agiog does['t
rcsult from a fo¡ward movcmcnt of Acial tissucs.Therefore it secmsillogical
that moving facial tissuesin a postcrior dircction would restorc a youthfi.¡l ap-
pearance.This explains\¡¡hy cxccssivclateral pull on dcep tissuesor skin pro-
duccs a strangc, unnatural appearancc,espcciallywhcn evaluating long-term
rcsults. For this reason,avoiding latcral traction is mandatory. Thc MACS{ift
hasbcenconccivedasa pure vertical-vectorfacclift tcchniqucfor the deeptis-
sucsand skin.

The following pa¡agraphs(pp. ó-fI) proüde an overvicwof thc undcrlying

principlcs and opcrative stepsofthc MACSJift techoique. Individual stepsare
illusuatcd.
Short S.ar l-¡cc Lih Te.hnillL,cs

OPERATTVE OVERVIEW
Principles
The MACS-lift is a short scarfircelift th¡t clo,atesthc deeptissuesand skin,
usinga vcrticalrcct<>ronl¡'.Saggingfacialsoft tissucsare sus¡rc¡rded u,ith per-
nrancntor slorvlyresorbatrle ¡rluse-stringsuturestltrt arestroneilyxtrchoredto
thc cleeptcmporll flscil through a prciruricularand tempor¿lprchairlincinc'-
sion.Thc f'ollo*ing nvo variationsofthc proccdurcxrc possiblc:
. Thc sinrpleMACS-lift(S-MACS):1'wopursc-string suturcsxre pl¡ccd
to correctthc neckancilower thirclof thc fircc(cervicomental rnglc,
jorvling,anclnrarioncttcElroovcs).
. Thc crtcndedMACS-lift(X-MA(]S):A sup¡rlemcnrar.v (third) pursc
sttirtgsuturcis useclto suspencl thc malarfht pid. This strturcwill hirvc
irn cxtra ellcct on thc n¡solabiirlg¡oovc, thc midf'lcc, irnd thc lorvcr
cvclid.

Operative Sequence
Wc bcgin to mark thc incisiorrat thc los'cr limit ofthc lobulc, anclcxtenci it u¡'r
into thc ¡'rcauricularcrcasc.At thc lcvcl of thc incisull intcrtrrgicl, rvc irnglc
thc mirrking90 dcgrccspostcrior to prcsclvc thc i¡rtcgrityof this itrittomic
hnclmlrk. TIrc nrrrking is conti¡uccl irlon¡t thc ¡rostclior cclgc of thc trirgrrs
¡ncl ¡scc¡¡dstou'ardthc hclicrl root. At thc sur¡criorIi¡rritofthc c¡r. tltc nt¡rK-
ing f'<rllorvs
thc sm.lllhiirlcssrcccssLrctrvccn thc siclcburnlncl thc luliclc, itnd
thcn turus do\ynw¡rti to fbll<¡wthc iDf!rior hrirlinc ofthc sidctrL¡r¡r.

In mcn, thc Drarkingdcscc¡dsilpproximatcly1.5 cnr trcfirrctL¡rningantcrior'ly

to crosstllc sidebunr, Wc coDtinuc the nurking fbrrviucl iÍr a zigzirg prttcru 2
nrm $'ithin thc lo\\'cr¡ncl ¿ntcrir¡rhairlincofthc sitlcbum. ln tlris part ofthc
incision, rvc i¡rcli¡rctl'rc knifc at ¡n anglc alnrost tan¡¡cntialwith thc ski¡r t() cr¡t
hlil shirf-ts
pcrpenclicul¡rly. This mincuvcr u,ill allow hnir to grolv through thc
sclr. Aficr lrlir regrowth, thc finill scar \\,ill trc hiddcn r firr nrillir'¡cters rvithilr
'fhc
thc h¿irlinc lnd bccomc lirtual\' invisitrlc. ¡rur¡roscol thc zigzag pnncrn
is to incrcrsc thc lcn¡¡th olthe tcm¡roral incision fbr bcrter fir with thc lcngth
of thc clrcckflirp,thc¡'cbyredocingdog cir fbrmiltion. ln thc simplc MAOS-
lift, the incisio¡rs'ill cxrendto the leyclof tlrc latcr¡l cirnthus.In ¡l extcnclcd
MACS-lili, thc incisionextendsto thc lq'cl oithc t¡il olthc clebrou'.

Preoperati ve M a rh i ng: U n der m i n i n¿

Wc pa\'retcthc manclibular
anglcrvith tlrc indexfiuelcrand or¡rk this ¡s thc
Iowcstpoint of unclcrnrining.Thc extcnt of thc undcrminin¡¡is then mirkcd
starting fiom the lorvcst ¡nint ofthe incision at thc k)bulc, extcDdirg tosard
thc narking oflhe manclibulallngle, and then curving anterior\,to 5 to ó cn
 l hc ll\\cf ofü. Sh,rJ S.¡, \.úi.il fr.c l.ili

in flont of thc car.With rn ertencledl\,lACS'lifi,rht' Lrnderminin!!of'thc mrl.rr

cnrinenceis inclucledin the dcnr¡rc¡tion.We untlernrinethe sL(inL¡sin!!llees
tlpe fircc lifi scissorsin the sr¡bcut¡¡eouspLrnc. l hc ¡ñchor poi¡ts fóf the
pursestfing srrtufesirfe u ithin thc dcep tcnrpo¡l tisci¡ irbovethc zygomitic
luch, in i sill¿zone oLrtoftllc fi¡th ofthc f¡ont¡l br'¡¡ch ofthc fhciirlncne.

,L
Sho.t sc¡r Fd(c Litt TcLhniqocs

The Fit* Purse-String Suture: Tlte Vertical Loop

To make the lir-st pursc-string sutllrc, \\'c usc iris scissorsto create a li¡rdol
0.5 cm in di¡mctcl ir'rthc slrbclrtirlc()Lrstissuc, I cm above the zvgonratic ¡rch
antl I cm in fiont ofthc hclicrl rinr to cxposc thc deep te¡nporal f'ascia.Wc usc
c I 0 PL)Sst¡turcon ¡ l¡rgc, ¡<¡undCT.3 needle.The fir¡t bite is takcn it thc
¡roint uhcrc thc dcc¡r tcmpor'irl firscinis visualizcd, and cxtcnds clou'n to thc
tenr¡ror:rlbonc. Wc olicnt thc nccdlc torv¿rclthc tragus to avoid danra¡¡ing.r
fircialnervc b¡¡nch. Wc tLrl<c hrnr LritcsI to 1.5 cm long and 0.5 cnr dcep irl
thc su¡rerlicialnrusculoir¡roncurotic s,vstcnr (SMAS) tissue,rvhich co¡tsistsof'
p:rrotidlisci¡ in thc uppcr t\\r) thirds iurd plirtysn:riD thc lorveronc third.

Wc suturcciorvnto rhc l<¡lvcrlinrit ofthc Lrnclcrnining. Thcrc,'"vctakc tlo <lr

thrcc solid bitcs in ¡hc cr¡niirlc(lgcofthc plirtysrr¡r¡usclc.So¡rctimcsthis rc
quircs crtcnrling thc L¡n(lcrnlinings until thc plitysnlil
firr I to 2 c¡r ciruclirlly
bordcr is rvcllvisLrirlizcrl.
Ar this ¡roint,sLrturingis dircctccluplv¡rd ¡ncl conrin
ucs l¡ack to thc stertin¡1¡roint. 1'his (rcitcs ¿ larro\\'U sh:r¡rctl¡rursc-strirrg
loop witlr l rviclthofirb()ur I cnl. lVc tic thc knot unclcrm¡xim¡l tc¡rsion.

TlteSecond.
Pttrse-String Sutarc: Thc Ohlique Loop
Thc scconrlpursc string srrtrrlcoriginatcsfior¡ thc samc bcati<¡r ¡s thc hrst
( the dccp tcmporll fiscia, f-ormi¡g ¡ N'idcr loop dircctccl toNarrl thc jortl
irc¡ irt irn ¡nlllc ol 30 clcglccs \vith thc lcrtic¡l loo¡r. This loo¡r is nxrrc ()-
slrir¡rccl(conrpirreclrvith thc Li-shirpcclvcrt¡cirl l()()p) to prcvcnt linc¡r rr¡ctit¡r
(¡r thc sLrbc!¡t:l¡rc()!¡s
tissr¡c,\vh¡clrc()oldlrc visiblcth¡or¡ghthc skirr.Tlrc ltxr¡r
firlkru'sthc borcic¡s ofthc rntc¡iot undcrnri¡ringin rhc l()wcrp¡rt of¡hc chcck.
Wc tirkcslrortbitcs (tllilx¡urumof I cnr) in thc ¡rirrotidfirscia¡nd thc SMAS trs
suc.Wc thc¡ tic thc knot undcr nr¡\inrirltcosi( .

Tbe Tbi.t tl Purse-Stri.ng Sutare: The Malar Loop

Thc tbird suturc hls l sc¡llrtlrtc irrch(n p()int (ln thc clccptcrnpof¡l firscir,jusl
l.rterirlto the latcr¡l orLrit¡lrim in fiont ofthc p¡th ofthe fiont¡l br¡nch ofthe
fhciirl ncrvc. Hcrc, n,c mlkc ir rviodow in thc orbicul¡ris nusclc down to thc
dcc¡r tcmporll fisci¡. We t¡kc l dccp bitc, ¡nchoring tirc slrturc to thc clecp
tcmporal firscia.The pursc-stri¡1gsllt!rfc is oricntccl obliqucly clo*,n* lrd lncl
¡nediirllytorr'¡rcjthe nral¡r flt pi¡d, $tich is rccognizrblc bv its more fibro[s co¡r-
sistencvthir¡ the surrornrding sLrbcutir¡lc()us fir¡. A¡ thc preoper¡liveh m¡rkcd
point 2 cn belorv thc latcml canthus, \r'e revcrsethe direction ofsuturing up.
rv¡rd ard l¡ter¡I. Thc loo¡r hls l rurros U'shapc alcl cncls at its startirg an-
chor point. The knot is ticrl t¡nclcr¡r¡ri¡r;rl tcnsion.
 Th! fu$!, !l Ll,( \Lut S..! \t,Lr.ü f.(( L,lr

((tt\\
l0 \h(¡¡ s.tr f.,.c I ilr lir'!irqurs

Shin Redrapin¿¡
()nc ol lhc nr()\timp()rt.rntt!:.rtu|cs ofrhis shr¡rrse. l¡cc lili is rcrric¡l sl<i¡rIe
i l r ' . r p i n rl li .c e . r t r st he c \ e . r ( n ( ) 1S t r 1 , \ S s u s p c t r s i (i )i .t r) l n t o r tI r L r c h\ c f l i e . r l f. e
d l r p i n gr n t l r c s c . l i ( ) n ( ) f t h c s l ( i ni l t t h e s ¡ n t cd i r c e r i o lrtri l l s c l l ¡ h c u n ( l c f l v i t r s
sul¡cul.rrcoos\clrll)fin!acff¡.1 ln clrrssic¡lficc liliing. fhefc is il\\'.r\s.r ho11
zorrtitlconr¡rorenfrf sliin rctl|rrpinqlh.if (ilUscssliill crccssilt tltc c¡lkrLlcrc
qion. ncrcssit.rting ¡ fctr().urri(ul.lfirrar\i{)nfin sl(itrfe(ir.ll)ing.

-----_ c?/
I
L
e

Skin Rcscction
Wc fc\cct skirr()n thc chcel(flirp in u eLrlvilinc,rr l.rshi()tr irtrdsL¡tLlr-c il t¡r tltc
zir-\z.L r qr o r r: r ' o l t h c t c n r ¡ r o r ' l.tr¡l i l l i l t ci n c i s i o l . l h e z i g z l g i n e i s r o lst t l l n o l
o p c n L r pr h c n ( ( ' . r l ) r i n r! r: .' i l ht l l c l i ¡ t c J rc l j e c kf l ¡ | . r l t c l c l r v . ( ) r l l ) c r r \ . t t i lti1, fq
tlle in.(nqrucn.c in lcnetll of hrth l¡ttlcls ¡nd ,rlsor'ctlLrcins pr;ssilrlctlrxl
c.trs.\\t sct b.relithc ¡rrrllcriuP e¡fl¡)l)cintr¡ thc clrcclill.rP.\\t Lrcginclosrr|c
\ i t h i n t c f r r ¡ l ) l c -( {i 0 \ ' i c | r ' lb u l i e ds U t u r c isl t t h c s u l ) r f i { )cr n c jo f t h c i D c i s i ¡ : , , .
W c s u t r r r cl h c h r r r i z o n t .lri ln t b o l t l l c i l l c i s i r ¡ln i l h . t l L r n n i n q5 0 n v I l l l t o ¡ i
/()l1t.rllrrrrtfr'ess sLrlr-c. t:rkinqlrig¡.r,cr Lriresorr ¡he cltccli fl.tpsidc tlt.rtrotr rttc
tcnrporrl sirlc l().()mpcns.r¡cfi¡ tllc lilt¡l incongltrtnec in lelr¡rll Lrct\\cc¡t
both sidcs.\\'c inscrt¡ snr¡ll.hollt¡r, siliconcclr.ril.rqcrrrtrcrt rhe Ilrcst ¡lrint
ol ¡hc incisiont¡r cl¡rri¡into thc lxrs¡: rc¡r'o¡uricLll.tf Jr.ssinq drrling rhc lilrt
2 - 1h o L r r s , ¡ l i c l r v h i c l ¡ i t i s r c ¡ r o r c. rrkl l t s r v i t h t l l ( l r r s s i r t r tlsl t. e r c s t o l r h c s l
l r r r i n gi s p c r l i n r r r c \(ill 1 1[ u n n i n l ló 0 n v l o ns u r r r r c s .
 l h . l 1 ¡ , c , { ) 1 r r \ r n I s . ¡ \ n r i . r l l . . r ' .l i i r I]

t4 \rl /I
\

,{
fit
Instrumcnts
'li)
l i . i l i l r r l c , \ l A ( l : Ii i l i ¡ i n f g c r vt l r r ( ) L r q l rs.lrr ( r - itn c i s i ( l rlr\ ,1 ) i r r s L f u r ) r c (r il \sl r
.dn\ Sufqic¡1,Ine., l,.rl<clirrcst. IL¡ rrclc option.rllvrrrrrlilicrl.lhc lirlccpsrr
20 crtt long rvith r \lr()nq.2 nrnr wi(1.,fl.r, iii¡r)ronclpl.rtlirlnr.lt is ¡rrticLrl.rr'lv
hclplirl firr tlccp rrolk ¡t thc l)l.tt\slt.rll)()f(lcr.rr'hcrcit c¡sill qf.rsfsrhc h..r\\
r ) c e ( l l\c\ ' i l l l0 l ' l ) S \ L ¡ l r ¡ f c .l h , : n c c . l l cl t o l c l cils 2 0 c n r l { ) t ) qw i r h : Lc r r r r c t tl i ¡ .
r r l r i e hc ¡ h ¡ n c c sr i r u ¡ l i ¿ ¡ t i o rorf t h c l ( ) l )( ) l r h c i n s l r u n r c nr tr h i l cr r r r i r r qi r t l r e
rl.t¡r'orrtrrrrtcl¡hlouclt tlle shor'¡sa.rrinarsr()n.
12 'Icrh.ntUc\
5h, 5(.ú fr.c I-ili

CASE EXAMPLES
Aficr7\'e¡rsofperf-online,NfA(lSlilis.lch¡r'cbecr¡nre¡l.a¡cofthcst¡bilirv
of thc rcsult comparedwirh r¡¡cliriol¡l licc-lili rechniqucs.Thc first f.rricor
clescribcci
prescntsan crentplcol-thisstr[)ilitr.Shc\rastrcetcdlcrr c¡rh in our
llA(lS lift scricsrnd l.rs.rlso plcscnrcdilr thc first lolurDe (seep. l7.l). Hcr
rcsultsh¡\'e ¡rersistcdirntl still rpl)c¡f lrillural.dcspiresobsequcntxgc rcliltcrl
ch¡n!¡cs.

Aestbttic Analysis
'l
his 5l ,vcarold rlrrnr¡n \\'¡s()pcrirtc(l()o ó yc¡fs ¡e(). Shc preserrtcd !\'ith vcrv
In(xlcritc Iaxitvofthc u¡rpcl ncck.rndt h e ' ¡ . u l , , r j r , \ r l i r ) 8H. . r l r c . ] l I l c l \ ' . ' ,
l)cIfi)rnrcdundcr krc¡l irncsthcsiir\\ ith irllr¡nrtrscr¡l¡r nridrzol¡nrscrl¡tion.

Sargi.calPlan
'l'hc
trc¡t'rcnt c()rlsistcd
ol:
. A sinrplcMA(IS'lifi
¡ l-inritccl
sr¡bmcntrllilx¡scr¡lPrr¡rc

Postoperatiw Rcsttlts
I'rcscnrlt'.shc h¡s ¡ r¡<xxlor,.rlficirl sh.rPc,sirh sliglrt rccrrrrcn.cof jorvling
c.ruscr'l
P.rrtlt Lrvr g.rinof 3 liq in bo¡.ltrvcig,hr.I hc ccrviconrenrrrlrrnglcis still
silinificilrtlvbcttcr rhin it rtrs prcr4rcr.rrirclr'. lltc infi¡m¡l¡rr hollt¡r, is srill
rticclva()rrcctcd.

It is inrpoft¡n¡ t() lt()tc tltr¡t irlrhoLrghthc eging ¡roccss c()ntinucdi¡ficf ¡hc

Proccriure.r¡clclficc liii stiqntill¡sUCh¡s thc lifcf¡l swcc¡rphcnontcnorr$crc
rx)t irppirrcnl.l lte vertic¡l vcar()rci)nrribr¡1cdrcl)r¡fkitL)ly
to thc shortcningl)l'
lhc sc¡f. fenderingrctn)¡!¡ficulitfLlisscclion oLrsolcte.Arlhcrcnccr() rhis l)Íin
ciplc iu ncirrh T(X)Pirticrtssincc )999 lt.rsncrcl tlise¡rpoinrccl Lrs.
'l'hc
l).¡vcr ofthc Short S.¡r V€rdcal Face l-ili
I4 5h,fl \..tr Ir.c Liti l¡.lu,nt,,c'

'l
fi¡' rrsimplcMAOS-lili.Thc l.rst
hc ncrf fir,cclscsPrcscntnpicirl in¡.licirtions
fivc c¡scsbenelitcdllr¡rr the ¡clclirionrlniclfircec()rrccti()n
oflircci b| ln cr
tcnilctl ,\IACS Iili.

Aestbcti.cAnalysi.s
'l'his .15-r'c¡r-olcl
()f thc l(n\cf lr¡ll of hcr'
rrrrlirr h¡cl .r eicllittctiirppeitr-itncc
fircc.nriltl l¡rin ol hcr uppcr rrcck ¡¡d subIncrrt¡l rcltion. irn(l ¡ "h¡rtlcncd"
g.rrc.

Shc h¡!i rrr()clcf¡tcjo\ling, irn r)l]scl ()f subnrcDtll l.rxitvrvithorrt ¡rlirtlsntirl

b¡rrrls..rlri Drilri(nlcucgr(x^cs (nr¡inlv visiblcirl rhc pr()filc\ic\\ ). Shc hrs r
g,<xxlrrrirllicirlshrr¡rc,crccp¡ tin-J¡ infiirnirl¡r'holIl.. in thc chcck. l-hcrcrr'¡s
nr()(lcr'.1¡chcrniirti()nof thc I<¡vcr'(n1,lit¡lfir, .rn rr¡pcr blcph.rlocltrlrsis\\'irh
thc l(x)scuplcr c1'clicl skin fcstinq ()n lhc r¡ppcfciliir,hcrni¡tiolt of thc u¡pcr'
rncl ¡ cl¡bcll¡Í lit¡vll Iinc. lhc ¡osition ()l'thc clcl)r(^vswirs
nrcrlirl lirt ¡r.r11.
.ldcqu¡l c.

'l
hc ¡roccriurcrv.rscloncLndcr Lrc.rlilncsthcsi¡lrirlt i¡tr¡ntr¡scul¡l ntirl¡zol¡nr
'l
sctlirtior(3 Ing,)rnd r(x)l(2 hoLr|s. hc ¡irticrrtNirsrlischirlgctl2 horrrsp<,srr,¡r
cr'itti\cl\.

Nonw,gical Plan
'lhc
trc¡tnrcnt consistctlolr
. ll()!ulinlrrrll()\in t() lhc c()fruqilt()r¡¡td dc$css(r'sltpcrcilii
rDLlsclcs

Sutgical Plan
'lhc
trcirtmcntc()l)sistcclol:
. SubDcnt¡l IiposLrcriorr $ ith rerl1(^¡l (f lit bctNccrrnc.k skirr
¡n(l so¡ncf.rt rcnlor':rltiom thc jorvls
.rnclplltysnritrrtLrsclc
. A simplc MA(is lili
. A lo\\'cf lid tr:rnsconjrrncrilirl
fit rcnrrx¡l
. An uppcr b¡c¡hiroplirstlr ith fcsecti()n()fskin ¡D(l rrrtricul.rris
¡lusclc, llrrdc()rrscr\-irivc
rcnl(rr¡l of lilt fionr thc nrcdi.rlcom
Pirrtmcnt
 lh. ll¡rcr ol LhrSllifr 5.¡r\cr(i.r l-i.. I it¡ l5

Posto?eratirtResults
'lhc
I iclr postopcr-¡tivc rcsultsirreshorrn. l hc tionf.rlvisr shr¡usr lcstorr
li()n ()l 1hclolcr fici:rl shr¡rcwith r lcll dcfirrecinrlndibrrl¡r b<¡rtlcrlurl cor
rccli(rr ()11hcjo\\lin¡r,entl mirioncttc ¡5rooYes. Lorverct'elirlbulging,.urrlu¡r
pcr'cvelirlblc¡rh.rroch.rl¡sisrrc corrccrcd,rnrl thc gllbcll.ir'rcgit¡ris solic¡rcd.

ln thc oLrlirlucliur', bcttcl rlcijnitiorrof ¡hc rrr¡rrclibul:rrbt)rdcr :tnd inrpr(^c(l

lirllncssr¡l'thcchccl<¡rfccvi(lcnt.th¡rrlist() \crlicill rcl)()siti()ning,
ofkxcr tirci¡l
rolunrcs.In thc px)filc vic\\, drc fl¡t su|.rlrcrrt.rl
.rrc.r.rrrrl
lhc crispccr-r'icotlcn
l¡l .rnglc.lrc()l)vi()Lrs.
Also notc thc gorrl qlr¡li¡\'()l thc sc¡f.lnLlthc nrltlfrl irs
( ) 1
l)c(f llrclcrrrp(¡-h ¡ lx i r l i n c .
I
ló S h o r ¡ S c ¡ rl a c e L i l i ' l ¡ c h h i q u c s

Ae*hetic Analysis
This 52-yearold wonr:rnw¡ntcclficial rejuvcnationu,ith minimalinvirsiverrcss.
Shewashoping that a nonsurgicaltreatmc¡rtcould be oflircd to hcr. Sheprc
scntcdrvith moclcrateupper ncck and submcntallaxiw s,ith ¡ srnallplawsmal
band on the lefi siclc.The patienthad obviousjolr4s,mrrionette gr<xrves, and
uppcr lip rl.rytids,with a youthfirl midficc ¡nd very ñnc rhytids i¡r thc lorver
evelid.Shc had untlergoneiur u¡r¡relblepblroplasty5 ycarsbcfore.
'l'his
proccdurervrs¡'rerfbrmcrllrnderlocal¡ncsthesia*,ith intramuscul¡rmicl-
azol.lmrelaxitiur(2.5 mg) andtook L hour ¡nd 55 minurcs.Thc paticrrrrvas
dischrrlgcd2 hourslftcr surgcry.

SatrgicalPlan
The trcatmentconsistedof:
o A simpleMACSlift
. Submcntalliposculp rc
¡ Erbium:YAGlaserresurfacingof the upperlip rnd corncrsof the
mouth
. A lowcr cyelidpinch blcpharoplasty
The Powerofthe Short Scarverrl. lacc Lift lz
T
l8 Sbort S(if l¡cc Lili ltrhniqtr.s

Postoper&tite Results
Results
¡rc shorvnI vearposto¡rerativch,.
Tlre rejutcn¡tingefltctssceni¡ thc
lou'erthird ofthc firccincludccorrectionofthe subn'lcntaland üpperDccklax
ity and of the platysnralband on the lcfi side,disap¡rc:uarcc of thc jorvlsirncl
mariorlcttegroovcswith better clcfinitionofthe manclibularlinc, lnd eraclicl-
tion oipcrioral rhyticls.Notc ¡lso the plcasingaugmcntarioncfl¡cr in rhc zv-
gomrtic rcgion that can be <¡trt¡inedo,cn rvith a simpleMACS-lili. A k^vcr
cveliclpiuclrtrlepluroplastvwasaddedto thc proccdure,which is seldomrk¡rc
in .rsimplcMACS-lificme.At the end of the proccclure, extraskinthat gitl')
crs in tlrc lor¡'ercyclid asa rcsult ofthc vcrticallift cirnsafell'bc removcd.ln
'fhis
thiscasc,4mm of skinwasrcmovcdespccially in tlrc prrrcanthalrcgion.
cxtririútcrvcntion¡rroduces minimalmorbidity(sccthc l-weck postopcritivc
photos). TIre postopcr¡tivcprofile vicw with clorvnrv¡rc1 gazing shou,sldc-
clultc :utl steblccorrcction of the cerviconrentalanglc. Rctrolr,rricularskirr
wrinklin!í is iDrproycdwithout iny incisionor disscctio¡rbehinclthe ear.
'l'his
pilticrlt is ¡ cirndidatcfirr chin :rrrgrrrcntiti(D(witlr ir chin inlplir¡t). Hor\,-
clcr, shcrvls not intcrcstedin undcrgoingthis proccclure.Although Icssinvl-
sivcth¡¡ classic¿l cxtcldcdfircclifiing,a sirrrplc MA(IS-liftc¡t¡scssonrcntor-
biclity.Whcn sutLrtcswcrc rcnrovcclI wcck postopcrirtivcl¡ somc bruising in
thc ncckind lorvcrcyclidswls visible,llong l,ith srvcllingin thc rcgion [rclorv
thc c¡rlot¡c. In this thi¡r-ski¡r¡rcclpaticnr,l fblclof¡rllq'snra musclcis visiblcls
l rcsrrltof uprvarclstrs¡rcnsion srrttrringofthc lirst loop. Tl'risbccor'lcsIcssa¡r'
pircnt in thc secondpostopcrrrtivc rveck.Subciliirryanclpirlaciurth¡lsc¡rstrr¡¡D
thc pinch blcph:rroplirstv prodrrccminin¡l cxtr¡ ¡n<¡rbitlitvThc rcsurficcrl
rrca on thc uppcrlip andcorncrsofthc rrroutllis alnrostcomplctclyrccpithc-
Ii¡lizcd¡t I rveek.At thistinc, tlrc¡rctrolrtunr/parrflio drcssing is lcpllccdby
l cliflircnt hydratingcrc¡m ¡ncl sL¡nblock, rd liuef ¡'nirkcupcan bc irclclecl.
 /y{k
,t)
ti
\-
"G
20 5lr(ú 5(I fr.c I-iti li.h.ntres

AesthcticAnalysis
-lhis
5,1Yc¡r'okl $onr.rn rcqr¡cstcdc()rrcctionof thc fe'¡turcsth¡r rD.r(lchcr
I<xrkollcr. Shc \'.urtcd t() collcc¡ltrirlc()n thc l()\\'crp:rrr of hcr licc lnrl rlirl
n()t \\'rl)r t() nn(lcrq().¡rvPr'occrlLrlcthr¡ involtctl ¿cncr.rl.rrrcsthcsi¡.
Shc h¡d
(¡nclcrq(lrtc r¡pfcf c\¡clidsrrrgcr! clsc\\'hcrc5 r'c¡r'sc¡r'licr.Shc h¡d ¡ rrunrl,
hc¡r l ficc r ith ()bli()rrsfiul infiltrilion ol thc rrccl<.

\Virh lhis l)xticnl,thc qucsti(rrirf()sc\\ hcll)cr t() ()pctithc nccl(¡ntl pcllirr-nr:rn

()|cn liIcctrnnvNirh cl¡br¡-¡tcrrr)fkoo the Plilt!snr.rrDLrsalc. suclrrs plrt|sn).1
ffhilplr!.'l hc nr()sf!lr¡¡rl¡lic rcsul¡sa¡n Lurtl<¡Lrbrcdlv bc ol¡t¡inctl br,,,',"','nu
'lltclc
¡hc ¡cck. is thc fotcnlirrl tirr highcl nrorbitlitr'.inelrrrlirrglolgel conra
lcscc¡ccrnrl Pos()pcfilti\chcnrrrtr¡rr¡.Fl¡chc¡sc h¡s ¡r lrc ¡tll¡csscLlinrliviLi,,
¡ll\ itn(l dis(ussc(l\\'ilh thc p.lticnl.In this c.rsc,ir lirs r.1cei(lcd()t l() ol)cn thc
ncck L)cc¡u\cof rhc ¡.rricDt'srcluct.lncct() Lto(lcrg() gcllcf¡l ¡ticsthcsi¡.

'l
his prrrccrlurcrr'.rs1)cftinrrrc(lur1¡.1cf l().¡l ¡ncsthcsi¡r'ith intr.rn¡usc¡l.rr nliri
. r z o l ¡ r trrc l ¡ r ¡ t i o r r( 4 r n g ) r n r l r r x ¡ k2 l l t ¡ L r r¡sn t l l 5 n r i n t r l c s l.h c p . r r i c r trrr ' . r '
clischirrgctl I hoLrrslficr surr¡clr.

Sutgical Plan
'l
hc o'c¡¡nrcnrconsistccl r¡fl
. Flxtcnsivc sul)nrcnt¡litld j(\vl liposcrrlptLrrc
\\'ith d f()wcf lssistcd
li¡xrsuction( I'At-) dcvicc
. A sinrplcMA(lS-lifr
¡ A kxvcr ct clirl Pin(h l)lcPhirr(Dlirsr)
. Flrl)iulll:YA(lliscr feslrrfi.inqol thc pcrior.llrhvfills lll ¡tro¡tlts
¡ltc f surgery
'l 2l
hc 11¡\rr ofthe Sho,r Sc¡r Ycr¡ic¡!r¡ce l.ih
22 Short S.¡r Fa.e Lili lt.hnig!¡es

Postoleretiye Retul$
Thc l8-¡nonth postopemtivercsultsshorv r marked changei¡r thc ovcrall
shapeof tlre facefro¡r round to more oval. Resultsfor tie cervicomcntalan-
gle and the definition of the mandibul¡r bordc¡ arc ve¡y satisiTi¡rg
in vicw of
thc limited work that wascloneon the ncck (only liposculpture).The possible
gain that could havebcen obtai¡redby openingthc neckis clcbatrble,consid-
cring tlrc potcntialrisksand addednrorbidity.

Thc cfl'ccton thc midfircea¡rdlowcr eyclidsis visiblcbut moderate.The tcm-

por¡l hooding at the lilteralpart ofthc cyebrowthrt is visiblcprcoper¡tivclyis
not corrcctcdby a MACS-lift and rcquircsa tcmporallift (sceChapters8 rrrd
9). Thc quality ofthe scaris good in thc preauricularand temporalrcgions.
Thc lo$c, ofth. Short S.¡r \tric¡l F¿ceLiti
21 s t i r nr S . r f | . t r r t . i h t ¡ . r , j , t u ( \

Aesthetic Attalysis
fhis'17 Ic.rr-old\\'()ntilnprcselrtc(lprinrilrilvfi)f r rhiúo¡rllstt..rncl
rcqr.rcstcrl
Int(r-t)t¡tl()n
lbout n¡txltiiticslirr t'irciirl
rcjrrrcn.rtion.Shc h¡cl s(¡treiiltrr irrfil
lr'.rlio¡t()l thc sutrmc0t¡l .lrcit \\.ith(,t¡r.ln\r pl
plrtr sntrl b:rnds.,\lxicr¡tc
ir¡rlirr!l
\\'¡s prcsc l; ¡hc ¡rcltitcctL¡rcofhcr nritlficc tr..¡sgrxx1.She.tlso
h.r.ls,,ntcu¡,
pcl blcphrroch.rlirsis, rvirir¡hc upPcl q.clitl sl(in¡lniosr touching rhc cili.r.Ilcr
rr()scsl)(^\c(iI dols:rlItLrntp\\,i1hsJightdc\iittion tr¡y. .clrhc
right sirlc Lrrl,lrr
br'<¡.rcl
til¡.

Ihis prrccr.lLrrc*:rs pcllirr.ntcd L¡nrlcrgcltcr-ll .rncslltcsiil.ut!l

'I
hc pi1lic¡ rvitsdischlrgcrl lhc s¡ntc (l.rv.

Surgical Plan
'l
hc rrc¡tnrc¡t cr¡rsistcrltfl
. Sul)ntcntillliposLrction ¡nrl sUcti¡¡t thc
. A sirn¡rlcLIA( tS-liti
. Arr rr¡rpcr[rlc h.rro
¡r ¡rhsrl
. ( ) l ) c t rf h i n ( ) p l ¡ s tNv i t l t l . c t lc t i o n( ) f t h c
l t U n t p l:rtcr¡l
, ostcoto-
nri.^s.¡nd :r lil) rhin()l)l¡st\'\\'jlhtf¡ns(i()n1ill tn(l i n l c r d o n t ¡ l
sUrufcs

PostopcratiycRcsults
l l r c P . r t i c l ti s s l t t ¡ r ' nl l l l r ( ) n r h sr i i c r . \ u r q c r v( .r t r l i - o ¡ t ¡ ll i c l . ¡
e l t ¡ n { ci l t r l t c
rcrrcf.rlsltrpc of¡hc licc ¡)\vlrd.r ntorc r.oUthlill,rrv.rlsh;rpcis sccn.'l
ltc rrosc
lt.l\ bcc¡rrclincd.¡n(ltltc ul)pcrblcl)lt.lr(4)l.tsl\, n.lsl)r-ovidc(l .r l cficsitinccll.:cr.
l h c o h l i q L r rci c r r s h o r v sl l t c s . L r l p l l t f i nc{ l i ¡ ( t ( ) r rthc i(^vcr
l)¡rl rf thc licc,
.rcacntu.llt¡t1¿ ll)c nr.r¡i¡rcr))i¡rcncc_ l lte intprorcti acr\ ic()¡lrctrl.r¡ itnqlc is scc¡t
¡)n lhe il()\rn\rtf(l g.rzirrgprofilc. Sltc rs rrscri¡r \\'cildn!¡ hcf
ll¡i¡ bchinrl ltcr.
clls.r¡trl continLlcsto rir so aiicr sul.qclv,bcc¡rrscfhc pfciruricLtl.rf
¡trLl lcrrrl)()
r.rlscrrsilrc ¡l,)tosrinr isilrlc.
'lb. 25
|(¡\f oint S]!r¡ \.i, \¡frri.rl I ¡.. Liit
)(l Sli,ú \.¡r h.. I rri T.tl irlr.\

AcstbeticAnalysis
_l
his .13 r'c¡r old rron¡.rn rcquestc(lli¡ciil rcjurcn.rtionanrl rr ls nrost cor'l
ccrrccllLroLrthcr ncck.Shc illsopfcscnfc(1 fit cr¡-rcctionof e LrLrlbousrr.rs.rlrip
.rrrtl brcesthv¡er¡l.rsi.r.

Shc hilrl ¡ llc¡rr', lilftr iullllfrtcd ncrk ryith ncithcl ¡ ccrlicoltrcntll ¡ltrlc ltor
nr¡¡rr.libul¡rrlcfiniti¡rn.Hcl miclficcsrill h¡Ll ¡ vouthlirl :rpfc.rf.rncc. ()l(l .rcnc
sc¡rsl crc r isiblcon l¡r¡thchcclis.

_l
ltc ¡rrocctltrlcrr'.rsrk¡rc rrrdcr qcrrcr.ll¡ncslltc\i.¡.l()()k2 hoLrrs.rrnclrr'.rs|cr
Ir¡nrcd br l\\'() tc¡nrs. lhc [irticnt st.rvcdorclnight ¡nri rvrrsdischir¡qc(lthc
nc\l (l¡\',

Su.r'gicalPlan
'Ilrc
trcrrtnlcntconsistctlofl
. Lip()sucti()uof thc sLrbrllctirl .rn,.ljorrl irrcir
. A sinrPlcl\,14(lSlili
. An u|Pcr l)lcPhir()l)lirst|
. l'lndonxsxllil) fhin()l)lirst!rlith lctluetion()l'thc ll¡r r¡rlililgcs
. Ilrc¡sf rcdt¡cti{)n

PostoperntiveResults
'llrc
p l t i c n t i s s h o r r ¡ I ! c ¡ r ¡ l i c f s u r g c f \ .N l ( ) s sl r d k i r r gi s, t h c c l 1 ¡ a l( ) n l l l c
l r r r c r ' ¡ r . r l to l t h c f i e c . I I c r - c e r v i c ¡ r r c ¡ t . r¡lr r q l c ¡ n ( l l h c r l c f i ¡ r i t i o lot l r l l c
rrr.r1(liliulrflr¡¡rlcr rvcrc rcstor-crlbr'si¡t¡rlt suctioningthc lir bcnvccll ¡hc
sl(in ln(l l)l.lrvsnr.l, irrrclsLrspcndiruthc l¡rcr-ll [r¡rlcr rrl'thc pl.rn'snrrr. r\rri
thirrq n)()fc,rqqrcssivc rvoLrklllltvcLrccnovcrtlc¡rrucnl. l]rc ¡alc rJc.rr\.rrc.rls,
i n r p r o v c c lo n s i d c r . r bl lsr . r l e s L r lot f t i g l t r c n i t r !r,h c c h c c l si k i n . l h c s c r r r L r h i ¡ l c
surgc|icscotrlclsrrlilr'lrcconrLrirlccl L)cc¡Lrsc ()l lhc d()ublc-tcrrrrr rrpProirch.
T h c l 1 ¡ \ e f ( ¡ d l r S l ' o r r5 . ¡ r \ : . n i . ¡ l F ¡ . . L i l i 27
28 shr¡J \.¡r ljr.. l. r¡ l..hni!u.\

AesthcticAnñ.Ilsis
'l
his 59 vc¡r'old rronrrrnpr-cscrrtcel lirr ¡ mininr¡lh inr¡sivc t.rci¡lrcjü\cn.lri()n
_l'hc
ploccrlrrlc. li)ll()\\i11S!
t-e¡tur'cs
\!crc rlost strikir)g:thc sun tl.rnr.rgctl. tinc,
rn(l Lr¡¡rcrnccli l.rritv.jotling, sh.rr¡n.rsL,
cf!:pcr.chst()licsl(irr\ itlr slrLrnrcn(irl
l¡l¡ill fi¡1dsc\lcr(liniI int() thc nrirri()ucttclal(x^'cs,¡ dcsccnt{)fthc Inidtilcc
wilh ¡ l(^v positionofrhc rlrllr fnr prr1,:urt1 l r¡¡r'licrlo'clirl cfrcckjLrrrction.
Shc h¡ti nrrxic|rrtcblcph.rroch.rl.rsis oi rhc r4r¡rcr$clirls.

'I
his pr'occrlrrlcrr'.rs¡rcrlirrn¡ctlrrntlcl krcrl irncsll)i:si.l
rrith intr¡nruscul¡¡-¡ritl
(.3
,rzol.r'nrcl.rr.rtion nrq) ir)(i ¡xrli 2 hours rnd l5 IninLrrcs. Thc ¡.rticnt rrs
tlischrlgcri2 llours ¡ticr surllcr'r'.

Nonsurgical PInn
'l'hc
tfcilt¡rctll c0nsistctlrf:
. A llctir) A skin crlc ¡r'ogrrnr

Sur"gicalPlan
'l
hc trcirtrrcnl consis¡cdol:
. SLrbrncr)tillliposucti0n
o ¡\n crtc¡dcd N{A(lS Iifi
. A k^rcr |inch blc¡rhrr<¡rhsr1'
r An rrPPc¡blcphrrropl¡slJ'

Postopcrfltivt llcsttlts
Ihc I rei¡r p()sl()l)cr.ltivc rcsulls (jcr)r('nstr¡tcc{'rrc.li('¡r of ncck sliiD l¡ri¡v
tlrrrrn ¡r the crieoiclc.trtil.tgc.lith r'cstor¡tir¡rol-thc cr'rviconrcn¡¡l¡tr,tlc.
I,liurrlibL¡l¡r rictinitionis res¡rcd hl colrcctionol thc jrrrrline. Thc nr.rri()ncllc
q l r x n c s h l v c t r c c nc r ¡ c l i c ¡ t c t¡ln r l t h c n , r s o l . r b il ¡i rl l i i s . r r cl c s s . r p P e r c nlth. c
rDi(lficcis rcjuvc¡rtcd irv littirtgofthc nr.rlrr-lit ¡irrl, .rrr11 rhcrc is r clc.rr\h()r't
cninu.ol thc rcni..rl hciqhr ol lhc l(nvcf crclid. thclcbr blelding rhc clclitl
clrcckjrrrrctiorr.'lhc u¡pcr cvclitls.rrcrcjuvcnirtcd.
The Powe¡ofrhe Shorr-ScdVerticalFaceLift
30 S h , r JS . r , F r . c I - i t i l . ( h n ( t r c '

AestheticAn&llsis
'l'his
54 r'earold \\1rran rcqucstcdnlinirnirlhiDrasivctirci:Ll lejuvenetionun-
cicr loc¡l anesthcsiir. Shc prcscntcdrvirh ln undcfincd ccrlicome¡rt¡l irng;c,
jorr'lsirnclnirr'ioncttcgroovcsrlossof dciinition ofthc j:rl1ine,¡ m.rrkcclrr¡-
solrrbialfirld, inLl flirtteningof thc ruiclfirceilnd zyliont¡tic ¡rea. Shc hirtl ir
nr(xlerrteLlppcfblcph¡roch¡l¡sis¡nd (()rrcctpositionol thc cvcb¡orvs.

'l'his
procedtrrcrr'.ts¡rcrfbrmeal !¡ndcrl()cirlancsthcsi¡s ith intr¡rnuscul¡rnricl-
relr\irti()n(.3 mg) al¡altrxrk 2 hor¡rsarld l5 nrinLrtcs.
irz()l¡r1r Thc ¡raticntrr'.rs
clischrrrgecl2 hor¡¡s¡ficr su¡ecf\'.

Sargical Plan
Thc trcat¡rcnt co¡rsistcdof':
. Subnrcnt¡llilrosuction
. An cxrc¡dcd MACS-l¡ti
. An uppcr blcph:lroplisty with rcscction ofskin irntl <¡ticularis
oculi muscle irnd rcm(^/irl of fit fionr thc mcrlill irncl lirtcr¡l
c(¡l1p¡r¡tlc11t
Thr l!\LL ufrhe shoit.5!¡r \ erical l¡ce I ift
32 Shon Scd Face-LiftT€chniqucs

Pottoporoüve Resalts
Resultsare shown I da¡ I week, and llá yearspostopcratively. Thc scries
showsthe progrcssionofmorbidiry Shewasableto resumche¡ socialactivitics
aftcr l0 dayswearingmakeup,At l7z years,we seea stablecorrectionofthe
jawline,jowls,marionettegrooves,nasolabial firlds,andmidhcc. On the oblique
view,a nice augmentationeffectin thc zygomatic arcacanbe seenaswell asa
smoother transitionfrom eyelid to check,with a shortcningof thc vcrtic¡l
height ofthe lowcr eyelid.On the profrleview,slightrelapseofthe obtuscness
of the cervicomcntalangle is evident.It is debatablcwhcther morc radic¡l
neck surgerycould haveresultedin a better long-term result.The quality of
the prcauricularand temporalhairlinescarsis adequate.
 l i r l l r r r ¡ , r , f \ , , f L \ . . i \ r , 1 . . r 1l r . r i . r I 33

,ffi
F,.
-< rr,. # air
4t

u s
ü t t

I !.¡¡, D ¡ : i L ! i ) e r ¡ l ! , -y
34 \h trr <cr fr.. LifiTL.hnigrls

Ae*betic Analysis
This 55 year'oLdworran presentedwith mild laxity ofthe uppcr ncck and sutr
lnental region without platysmal bancis.She had modcratc jorvling and rla¡i
onctte groo\¡eslvery marked ¡asol¡bj¡l folds, and :r lossofsomc volunc in thc
midfacial rcgion rvith a ma¡kecl nrsojugal gloove. She h¡d fine rh,vtidsin thc
lou-er eJ'eliclsrvithort fit her¡riirticllr.Shc had uppcr blephalochalasislvith the
loose upper eyelid skin almost touching the uppcr ciliir. Thc position ofthe
eyeDrowswas idequirte.

This procedure rvasperlbrmecl under local ¡nesthesiarvith intramuscular mi<l

azolam scdation (3 mg) and took 2 l-roursand 10 mi¡utes. TJre patient u'as
clisclrargecl2 hours :rfier sulgery..

SurgicalPlan
The treatmentconsistedof:
. Submcntalliposuctionwith removalof firt l¡etweenneckskin a¡d
rnn'clcrnd somcf¡t rcrnovclfronrthc jowls
plarysrn,r
. An cxtcndcdMACSlilt
. A lowcr eyclidpinch blcpharoplasty
. An upper blcpharoplastywith rescctio¡ofskin anclo¡l¡icularis
muscle,and conservativc¡emovaloffat from the mcdialand
rar!rúr lvrIP Lrrr!r¡rJ
Thc Po\c ofüe Shor¡ ScarVerri.alIa.e Lift
3ó S h ( r t S ú . l i c e r . i t tI e c h o n t u . s

Postope
ratitl e Resa lts
'l
he patient is shoun I ¡nd 2 vearspostopcrativclv.The frontal vie*s show a
gener¡l chalgc in the sha¡reofher iice fiolr rccteu!+rl¡r to ovi anclcorlccti(rl
ofjorvling and marionette grooves. Thc nasolirt¡ialfblds ¡rc softcncd ¡nd rhe
nidfhcc:r¡rpearsreplelished. Thc vcrticill height ofthe lorvcr cyclid is reducecl
:rnd rhe lou,e¡ cvclicl skin is tightened. Upper cvclid blcph:rroch¡l¡sis has bccn
corrccted,

In the ot-rlic¡rcvic$a better clefinition of thc m¡rdit¡tl¡r trorder is visibic ¡rs

well as tllc xur¡rrcnt:rtion etl¡ct in thc z,v!i()llt:lticreeion resLrltingfiom cranial
tlisphccnrcntofthe miüarfit pad. In the ¡rro{ile¡nd dowtlrvardgazingviols,
righteningofthc subnlcntallnd uppcr neckrcqion is oi¡vious.

'l
hc minimal ch¿l1gcbct\\'ecuthc 2 ycitf atld I yc¡r postopemtivcph()tos
shorvsthc stirbilityofthc result. lltc¡c is mini¡r¡l rclaxetionof tLrcu¡solirbi¡l
tirld, which c¿11 bc correctedLryficcing thc firltl rvith e V-shlpcd dissccto¡.:rnt1
micr(fit tr:rnspl¡ntiti<¡n.'fhisirddirion:rltlc¡tmcnt rvoukl l¡c ¡dviscdprimlrill'
in prticnts witl'ri shi4) r1:rsohbillliroovc (scc ¡tp. 172 173).

2 yea¡s póstopéralve y
 I lr. ll¡r.f tir'¡Lt Sr.r r !.rr \ii ¡i.rl I r.. Liti 3/-

lñ
F

2 years pósloperalve y
3ll Shoú S.r. Ii.c l-ift lc.hniques

Aestbetic Analysis

This 5l year olcl *onan prcscntcrl for trcatmcnt of carly signs of agilg. As
scenon thc froltal vic*, thcrc wls a loss ofsharp co[tours rvith :r slight loss of
clcfinitiol ofthc ¡r:ultlibuler borclcr, n:rrioncttc groolcs, e chrlrlverd sl:urt to
thc c()mcrsofthc rnouth, chcck ptosis,and an incre¡sedlength ofthe 1o*er
e1'eliclu,ith ¡ rrr¡rketilici cheekjunction. lhcre rvasa dcgrce ofuppcl bleph
¡r'och¡lasis.

'fhe
oblic¡ucviov to'cals jorvling ald lt'ticlliciirl¡rtosis,*ith rccluccrlmalu pro
jcctiolt ud inlirror't¡itrrl
hollorring.Thc profilc viov sho*s:r l¡luntc,rlccrvico
rncnt:rlarrglc:rndprorrorLnced nrlrioncttc ¡¡rooves.

'l
hls ploccdLrrcrvirs¡rclfolr¡cd u¡dcr localirncsthcsi:r
rvith intr'¡¡ruscul¡rr¡id
¡zolanr rcl¡x¡tic¡r (3 mg) :ind toc¡l<2 hours ¡nd l0 nri¡Lrtcs.Thc ¡rirticnt$as
clischlrgccl2 houls irficl surgcr'v.

Suygical PIan
Thc trc¡t¡'ncnt consistctl o1':
. SLrbmcntillliposuction
. An cxtcDdcdMA(IS-lift
. An uppcr blcphilroplilst,v
. A lorvc¡pi¡rchblcphirlopl.rsrl'

P ostop et'atip e Re su lts

Thc p:rticntis sho*n I ),c¡r'postrlrcr'¡tivclv. A ucll dclinccl¡r¡ndiLrLrl¡rbordcr
is sccn, restodng x youthflrl oval sh.r¡rc.'l'hc¡r¡ri¡rncttc ¡¡r<xrvcs hirvc bccn
com¡rlctclvcorrcctcrl,urcl thc corncrsof thc mouth ¡rc lificd. Thc chcclistncl
mitlficc arc rc¡rlcnishcrl, .rntl thc l¡rvcr cvclids rrc shortcnctl. Thc u¡r¡rcr lirl
chelxis hestrccncorrcctcrl.

1l thc oblic¡rreviov, thc most str-ikingt¡¡tlu-c is thc r-cclist¡il¡utionof niclficc

voluncs, tith l bcttcr ¡n¡l¡r prorrincncc ancl¡cst¡rrltio¡rof thc tircill ogc..
Notc thc blcnding of rhc licl-chccklnncrion. In thc profilc nd do\\'n$ruci-
¡¡rzing vicls, thc sh¡fpcncd ccrvicomcnt¡l mglc is sccn, rvith thc corrcctcd
n:r¡ioncttc groovcslnrl blcnclingofthc lid-chcckjnnction.
 lh. ll¡\.1 ()irr.5h¡!¡ \.¡r \.r¡.rL triü l-ih 39

;.._-J
40 Short'Scirl¡ce Lift Techniques

AestbeticAnalysis
This ó7-year old woman presented requesting facial rejuvenation with 'the
simple,lessinvasivetechnique."Shewantedonly surgeryunde¡ localanesthe-
sia and did not want us to touch her upper eyelid or eyebrowsto avoid
"changingher looks."

Despite her age, her facial architecture was still well maintained and her aging
presentedpredominantlyin the lower pa¡t ofhe¡ face.He¡ midfaceand eyelid
regionswere very well conse¡ved.Sheshoweda skin laxity in the neck down
to her sternal notch, with a heavyplatysmalband on the right side. He¡ cern-
comcntal anglewasreplacedby an obliquc line consisting ofskin and platysma
muscle.Sheshowedjowüng with elastotic,crépeyskin on top of it and a dor¡n-
ward slantto the corne¡softhc mouth. Shehad moderatenasolabialgrooves.
Her midfaceand lower eyelidswere fairlywell maintainedfo¡ her age.Shehad
moderatcupperblepharochalasis, with eyebrowsin a corrcctposition,although
slightlyptotic latcrall¡ producingsometemporalhooding.

This procedurcwasperformcdunder localanesthesia

with intramuscularmid-
azolam relaxation(3 mg) and took 2h hours. The paticnt was discharged
2 hoursaftcr surgery.

S*rgical Plan
The ueatme¡t consistedof¡
¡ Submcntalüposuctionandsuctionof the jowls
. A¡ cxtcndcdMACS-lift
. Alower pinch blepharoplasty
Thc l,^rc, ofd,c Shot S.r \'.ri.r! Fr.r Lili
42 Shorr-ScrrFace-l-iftTcchniqucs

Postolnratioe Revths
Resultsa¡eshownat 9 months,l7z years,and 3 yearsaftersurgery.They show
good stabilitywith minimal relapscofttre agingfeatures.A naturaland stable
¡esultis seenin the neckdo¡¡.nto the sternalnotch. On the profile üew, mini-
mal necklarity hasoccurredovertime, which canbe attributedto normal ag,
ing processes. The jowls, marionete groovcs,and nasolabialfolds are nicely
corrected.The midfaceshowsa more youthful aspectto rhe mala¡volume,
The lower eyelidis shorterin its verticaldimensionand the skinis tighter.Tne
upper eyelidsand eycbrowsdid not changc,becauseshe had requestcdthat
theseareasbe left alone. Lateral hooding was not cor¡ccted;an additional
temporallift would defulitelyhavegivenher a refreshed,more youthful look.

9 monthspostop€ráliv€ly

3 y€atspostoperal¡v€ly
 I rt lrnlt .i¡lr. Sf(rr S.r \irn.rl I r,.I r .13

\a.
s
I
á,

ft

r ' j,earsp.sr. r,.r¡ljre Lr'

44 Shórt S.d Facc-Lih Techniqks

BIBLIOGRAP}IY
Ba-ker DC, H¡nra ST,OwslcyJQ, et al. Tcn-ycdrfbllow-upon the tlvin study.Presented
at the AnnualM€€tingof the AmericxnSocictyfbr AcstheticPlasticSurgery,New
Orleans,April 2005.
Besins T. The "R.A.R.E."techniqu€(rcvcrscandrcpositioning cffect):The renaissanceof
the agingfxceandneck.AestheticPlastSurg28t127-142,2004.
ColcmanSR. Structur¡iF¡t Grxfting.St l,ouis:Qu¡lity Mcdicalftrblishing,2004, pp
295 297.
conziLlcz-Ullo¡M, FlorcsES.Senilityof úc f'acc-b.rsicstudyto enderstand its c¡uses
andeflects.I'lastReconstrSLng36:239-246,1965.
I'aul MD. Using barbedsúturesin opcn^ubpcriosrcrlrridficc liftirg. AestheticSurgl
26:725-732, 2006.
?cssatE. A¡ algorithmoffaci¡l aging:Vcrillc¡tionof Lánlbros'thcory by three-dimen
sio¡alstcrcolithogr¡phfwith rcfercnceto dle padrogcncsh ofmidfacialaging,scler-
al shoq alrd thc l¡tcrrl suborbitaltrougb detbrll1ity.PlastllcconstrSurg 10ó:479-
488,2000.
Wu WTL. Barbcdsuturesi facialrcjuvcnation. Acst¡rctic
SurgJ 24:582-587.2004.
 FaceLift
Short-Scar
In d,icntionsond,Techni col
Consid,ernt'ions
Foad Nahai
Sboft Sr¡r h.c Lift-l-echóigu€s

\)horr-sc¡r hcc-lifi techniqucsh¿r'e[Tccomean increasinglypopular option

fbr paticnts who scck facial rcjuvcnation with recÍ.rccdmorbidiry shorter scars,
and mini¡r¡l disru¡rtion to their lives. Thc MACS-lilt, S-lif't, late¡al SMAScc
tom1,,and numcrous other ¡rrocedurcs have bccn devclo¡rcd to a¡r¡realto a
broader ¡udience ofpirtienrs ()f¡ll agcswho desirc an o¡reraticn thtt produces
a more dramirtic lnd long-lirsting rcsr.rltthan c¡n bc ¡chicvcd *'ith fillers and
Botox, but is less i¡rvasivc\r'ith shortcr scarsthan traditi(mal face-lift procc-
du¡es. U¡rderstanding thc appropriatc indications fi¡r a short-scar procedurc
is essenti¡l to achicvir-rgoptimal rcjüvcn¡tion irnclto mectin¡¡ paticnt expectx-
tions.

Wby Do We Mahe Incisions?

l. To resectskilr
2. To girin acccssto clcc¡rcrtissucs
3. To do both
In Bost\i(k t III. E¡lcs l-l'1.N¡h¡i F. EDdoscopic
Pl¡sticSorg.rr.sr l4,isr Quali$ Mcdicll
hblhhi¡9, 1995.

M,v currcnt intclcst in sl'rort-sc¡rficc lif't cl¡tcs b¡ck to tlrc c:rrly dirysofcndo-
scr:pic pl:rsticsurgcry LrtEnrory Univcfsitv. As lvc soLrghtto urirstcr Dtininxlly
invasivctcchnic¡rcs, l'c wc¡c tirlccd to pondcr tl'rc ptrrposc of our incisions-
\'hethcr to resectskin, gain lcccss to clecpcrtissucs,<¡rl¡othf The ¡nswcr ultl-
m:rtelyinflucnccdthc ¡rl rning of orr opcritions, bccitrscwc discovclcclthis:
Ifthc incisic¡n*,crc onlv fbr ircccss,it coolcl be sigliliciurtly shortc¡ecll This ax-
iom a¡rplicsto all aspectsofacsthctic ¡ncl rcconstructile surgcr\'; llv il'lcision
that servcsnlerely ¡s ircccssto thc dcepcr tissuesc:rn be substirrrtiallyrcducccl
rcgrrcllessofrvhctl'rcr it is uscclfbr ficill sLrrger,v,Lrrcastsurgcry, or bocly con-
lounng.
 -a
5 \ u r 5 .J , I r e ' i i l r l . J r ' w ¡ ,¡ ' d l-'(¡l Co¡ndea.,our 47

This patient undc¡went an crdoscopic ncck lift, ilcluding platysma plication

ard rcck suspcnsionsutu¡cs th¡ough ¡ 4 cm submcnt¡l ircision ¡nd a I cm
rctroau¡iculu incision on cech siclc.Thcrc u,ls no skin cxcision.
-:

4¡J \l {L\! F r 'l l! rr LrL

\
A sinril.rrploccdLrlcr':rs p c r l i r l r r r c (d) n l h i s l ) ¡ r i c n t ,rr'h,rh.rrlplitl\'snr.r
b.rnrls
c\ccsssl(lnin fhc srrb¡lcrltrrl.rrc.r.
.rncl.rl)l).rfcnl

ñ 1 \ . r r r f c n lt c . h n i q r r ci i r f s h ( n f s c . r rl . r c cl i l i r c l l c c ¡ s¡ h c t r r r ( l c r \ t l r r ( l i r1rhs. r 1l l
i s l r o s s i b l lc( ) r c . o n ¡ ( ) u lr h c n c c k i r r . r r i I r r l . r t tch c l i t r b ( r l c ¡ n r J L r e l o l t l r e
p l i r \ s n n , t h c d i g l s t r ' i rcr r L r s c l c s . . ldnrdc s l r b r r r . t r r ( l r L g ) tlr. lrur r d ; ; r r r¡ rr ll i c . r rtch c
S\ l c r r s i vicn c i s i o n¡ss l o n s ¡ s s l i i r r e s c c l i ( )irsl n ( ) l r c
n r L r s c l \c\s' i t h ( ) l rnrr ¡ l ( i r r e
qLrircrl.LJltirr.rtclr,in puricrt selcction,it is ¡ll ¡tl¡atttrl¡t ¡ltnt,¡rrtl tllc.iccisir
l() sh()ftcnrhc sc¡fs¡eperr(ls()rrlhc sliin'sqLrili¡\ 11u(l qtr¡rrtrtv.li lhc l).llicnt
h¡s nrininr¡lcrccsssl,irrrvith rronl¡rl cl¡!li.itv, pcrmitting it t() fc(lrll)c rnd rL
L l i s ¡ i b L r t ¡c .l i r n i l c di n . i s i o n( r f c n ¡ ( ) s ( ( ) p irrr c c l(i ) f l . r c cl i i ¡ s h o u [ l L ¡ cs u c c c s t
 Shor S.¡r li.c I iti l¡di.:¡o¡\ i¡d ltch¡i.¡ tin,sidcr¡rio¡s 19

lirl. Hon'ever, ili the p.rtient lrrs l signit'iclnt ¡nrount of excessskiu ¡ncl the
qualitv ofthc skin is ¡roor rvith loss ofclesticit', thc ¡csults u,ill lot be as p1eils
irg, bccauscthc skin cxccssrviil pclsist dcs¡ritcthc dcc¡r tissuc rccontouring

llascclon that cxpcricncc,it is clcxr th:tt thc rolc ofthc skin is ¡rrnm()Lrnt in sc
lcction ofpaticnts firr r short-sc¡rthcclili. Ir is not onlv fhe rnroLlntor locil-
¡ion ofthe cxcessskin th¡t is iñpofti1r1t,b(¡t ¡lso thc qullitr, of thc skin.*

BENEFITS OF SHORT-SCAR FACE LIFT

Wll¡t alc tllc bc¡cfits tiom rctlucin.l:, thc lcngth of our incisionsiWhl should
thc lcngth ol'thc scrlrconccrn us, il lhe pillicnl h¡s ¡ eood resLrlllhxl is plcis-
ingl lhis thinkirrgis iiccc¡rtirblc ifthc scirfis !!,cllhiddcn ¡ntl hcrls u'ithout il
cidcnt, bLrtth¡t is not ¡lrv¡vsthc ci1sc.In ¡1\'crpcficncc,thc pfciuricLrl¡f¡n!l
lrctr¡grl scirrsirl\!¡yshciil $ cll. It is usLr¡llvthc sc¡li\bchin(lthc c¡r ¡n(l ¡h()sc
t() (lc!clo[]sc¡f hypcftf()phy
crtcrrdin!iint() thc lriiflinc thiit hi\,c tl'lctc'l(lcnc,\,
-fhcrc
LrnLirllifting fionr thc rctr()ituficular sulcr¡s. is irlsoir gr'cirtcrrisl<of hlir
linc nrisrlignnrcntlrchindthc cl¡.

Notc thc hvpcrtrophicposrauricul;uscar\ ith signiliclnt rlrifiine rwrl tionr

the p()stirLrricuhr
sulcLrs
th¡t is dcmonstntcd in rhis ficc lif't p:rticnt.

' It\ rll ,b¡ún út.ltt: lt, qralÚ, l¡,

trrrr!¡. 1n Inrovl.lt J I I I , l , ¡ . ! F l l , N r h r i f . I l i ü , r \ ( ) ¡ . I ' L . N
r i . 5 r r g . r \ . S t L o u i sQ ü ¡ l i h r \ l . d i . ¡ l l r t , l i \ ¡ i , , g .1 9 9 5 .
-'

50 short.Scir !¡ce Lili ltchDiques

tensionduring closu¡cis a contr-ibutingfactorto h¡r

It is arguedthat excessive
pertrophyand that elinination of tension'"vouldalso eliminatethis possible
complication.Dcspitc drcseexplanations,I believethat the ability to avoid
scarhypertroplryandmigrationaltogetherwjth a short-scarfacelift makcsthis
an appealingoption for properlychosencandidates. Theseare the compellilg
¡easonswhy many patientsprefcr short scar techniquesand why many sur-
gconsare ¡row performingthern.Theseare alsothe reasonsu,hy the efficrtto
perfbrm a short scarfacelift is wo¡thrvhile.Hou'ever,compromiscof thc re
sult to kccp thc scarshort is not in tbe bestinterestofthe paticrrt.I[ thc cur-
rerrt cnvironmclt i1 rvhichthe demandlbl short-scarand rninimallyinvasive
proceduresis oftcl driven by mediainterest.nd hype,it is important to kccp
the indic¡tionsfor short-sc¿rproccdrrcsclcarlyin mind to ensurethat the pa-
ticnt undergocsa proceduretbat providesthe bestchalcc fbr success.

INDICATIONS AND DBCISIONS

Experienccwitl'r endoscopicfacialsurgerytecchesus tbat it is possibleto pcr
form nost surgicalproceduresin the ncck through ¡illi¡¡al incisiolrs.Fur-
thcrmore,ifthe ürcisionis for access o¡ly, it can bc significantlyshortcncdor
cvcr-rcliminatcd,thcrebyallowingthe nornxl skin to redrapcand rcclistributc.
Horvcvcr,patientsu'ith cxccssskin or skin of poor quality will rcquirc rcscc-
tiol'l xnd longer ircisions.Thus thc decisionto proceedwitl't a short-scarfacc
lifi is basedon ¡ carcfulcvaluatio¡rofthc ncck skin.

Managcmcntofthc skin ir the neck differs fror¡ mnnagemcntof facialskin,

bec¿ruse thc Deckaf'fo¡dsmorc optiolt for skin redrapingand skin rcdistribu-
arc possiblc
tiolr. Exccllcnt¡csultsir ncck reco¡rtouringand neckrejL¡venntion
withoutskinexcisio¡.

The kcy to a good resultis to assess the skinofthe ¡eck and establishu,hcthcr
the excess, the e¡ltireneckpro-
if ¡n),,is rcal or apparcnt.lfthere is no excess,
cedureis pcrforncd through minimalincisions.Ifthere is realexcesssldn,it rs
important to dctcrnine the locationand qualityofthis excess skir. Thc length
ofthe skin incisio¡ri¡ necklifting rcflcctsthc location ofthe excessskin to be
removed.

Apparcnt cxccssskin will redrapefollowing tissuerecontouriDgl¡clow thc

skin,suchassubmcntalskir-rfollorvingfat removalin all three planesor digas-
tric and sub¡randibularglanclexcision.However,the skin must havesufncic[t
elasticityto redrape.It represcntsthc lorg sideofthe tria¡rgleredrapinginto
the two shortersides,thus eliminatiogapparentskin exccss.
 5I

SliiD Lcrlr'rpin¡lis rlcnrrlstr-¡¡crltirllrrrrirrqlit rcr¡ovrrl¡nci l)lrl!snrr pliciltion

thr()Llgh.rsubnrcnrllincision.A sholt prcrLrfi.ullrfinri¡ii(nrwJs Lrsed1()tighl
err rlre Si\1,\S.ludl() irrrpr(^c ()n lhc j()\vlsrrnrljlr\'linc. No sl<in\¡rs crciscrl
iionl tllc necli.
52 S h o , tS c ¡ rt ¡ c e r . t i I e . h n i q u c s

Rcal cxccssski¡ r¡relv existsin the submenlrl :rrca.llo\\'ever, when ¡rrescnt,it

nill ncccssitatca full sc¡r lice lift. ln ny erperlence, thc rcal ercessskin rc-
qrLiring:r ñrl1scaris usr-nll-vlbund in thc lolcr neckbelot'thc lcvelofthe th1'
roitl and latcrall,vor,er the sierno¡rastoid l¡uscle tnd behinclit. l)udng the ex-
anrination, thc surgcon should detcrminc aLcasrvhere re:rLcxccsssldn exists;
thc qualitv ofthc skin nust also be ¡ssesscd.Nc¡¡¡r¡l skj¡ elxsticity is csscntial
fbr:rll shor'tsc¡l procedurcs.P¡ticnts \\ho havc inclastic,sun cllrlaged skil]
rlrust h¡vc the full fetroiluricular incisi()n for a gootl rcsult.

'Ihis
r1so'iclcnccclirl ltcr skin'ssLrndrnlitgccl
l)irticnth:rs¡rrxrl skin cl!1sticir,v,
¡ppc¡r¡¡cc. Shc rlso h¡s skin crccssbckNvthc lcvcl r)l'tllc th)'r()idclrtil¡lic
lncl elong ¡ntl bchi¡rd thc stcrnom¡s¡rid ¡rusclc.A firll fltcc lifi itrcisiorr,irr
is rcrluilcd tirr ln o¡timll rcstrlt.
clrrclingir rcrroerrricul¡re)ifcnsi()n,
 s h , r ' \ . . f I : . , . e1 . i r i L: n l i . . r n r r i n L lT . . h n i . r l ( l ( r r ¡ . , i r r r \

Evaluatio¡r of the Facc fol Planning; Vectors and Incisions

lhc skin cr'.rllltior rrlsoinfl¡cnccsnr\ chr¡iccol-\,ectors.l'he vcr¡ic,rlrcctol
ir¡plicclto the rreckirr conrbin¡tiontilh r l.rcclili rr'ithvertic.rlSMAS,rnrlvcr''
tic¡l skirrelevirtio¡lrill clclinc¡n,.1inrplovcthc je*lire lnd, to ir ccrtirincrrcnt,
rhc subnrc¡rt¡l¡¡c¡. Thc nrolc rlilgrrrrll lcetor'r'cquilccifirr skin rcscctionirl
rhc rctr()ruriculrrrre.rl ill rlcfinc.rntlinrprovcthc lou cr :rndlltcrel ncck rvhcn
.r lLrllsc.rreppro.rchis indicitc(l.

Lnc¡s¡on
lor lu scaropenapproach

lllc hl¡cli ¡rrrx\'sdcn()tcthc vccl(n-slirf dccP tissue,SMAS, irn(l pl¡tl'sm¡ l)li

e¡tion. lhc rc(l ilrr()\\'sfcflccl llrc rc(t()fs, rcfticirl fi)r thc licc irncldiirgorr.rl
postcriorlrtirr rhc ncck.(iivcn rhc l¡ck ol cl¡sticitrof rllc ski¡ ¡rtl thc krc¡tion
ol thc crecsssl<in,this ¡reticnrin nrv hxndsis n()f ir !¡()or1 crnr.lirl¡tctirr ¡ short
s c ¡ r ' l i c cl i t i .
Short S.¡r Iace Liti ltchniques

The Ideal Candidate

The idc¡l canclirlatcfor a short-scar Urccancl ncck lift h:rs nor¡nal skin <lualitv
u'ith no¡mal clasticity aod rro reel exccssskin il1 thc neck. The paticnt will
demonstratc jon4s anclaging ofthe neck ficc i¡tcrface.

'l
his paticntcxhibitsjorvlinglnd llci.rl rging, cvcn though hcr skin h:rsnorrn¡l
ellsticiq,¿¡1¿is llot iD cxcess(an iderl clnclidetcfbr ¡ sl]cntsclr Proccclurc).
'
le vectors f'or tlccp tissue ¡nd sl(in plicrtion erc <lcmortsttatccl,lncl thc pnr
poseclshort scarincisi()nis outlilcd.
 Sl on 5,¡' I .e frÍi t,rJrLi ons ,¡d rc.hni.i LonnJ{ -Lun, 55

Thc paticnt is sholvn 4 yearspostoperatively;hcr jowling has becn elimi¡tlrted

:rnd a pJeasingrecofltouri[g of thc sul¡mental area ancl jatvJinehas been ac
-Ihe
complished. natural appca¡aDccand projcction of the tragus have been
preserved.The retroauricula¡ vicrv is sho'"vn1 year postoperativel_v
\ h . , t S . . , rf ¡ . c l . i i i T ( . l r . i ! L , t s

l)ne ofthc rrrostusclirlnrcthoclsfbr prcoPerillitcc\'¡lLr.rfioll ()fthe prticnt 'rse

c¡¡did¡tc firr ¡ short scatProcctlrtLc is to lcrtic:tlh'clc\¡te lhc skirron thc side
ofthc paticnt'sllcc just in liont ofthc tr:rgtrs,rhcrct-rsirllulrtirlgtlle lcrticrrl
rcct()rs()fthc short sc¡¡ fr¡celit't.With rllv hand elcr'¡tinsthis tissLre, I obscrrc
thc jLrnctionofthc c¡rlol¡e.rnd thc neck ski¡. I1 thcrc ilrc no fi)l(ls()l c\cess
p()steriorlvL¡cr'olldth¡t ¡rc:L,thc P¡ticnt is ¡rl c\ccllcrlt cilllrLr
skin cr,tctrtlin-e
cl¡te lirr ¡ short sc¡r'lircclifi. lfthcrc is crcessskirl t¡- ¡ tirlcldelclops therc.
thc thc pirtic l is bcst sr.rilcdto r firll_scllprtrccdtl|c.

l his p.rticntis irn irlcelc¡ntlid¡tc tir ¡ sholt sc.rrfhcc lifi . Thc \crlicll vcct()r.
¡ denronsrratcd bv thc crarrincr'shirrrcl, rlocsrr()lrcsultin ¡nv lirlds r¡fcrccs'i
ski¡ bchinrlthc errlobc
 Shorr-Scar
FáceLift: Indic¡tionsmd Tech¡icalConsideÉtióDs

This patielrt is not ¿ candidatefo¡ a short-scarfacelift, becauset}te vertical

vector demonst¡atedby the examininghand resultsin folding of excessskin
bevondthe ea¡lobe.
5ó Short.Sc¡flacc.Lift Tcchniques

I weekpostopefat¡voly

4 weeksPostoperatively

Tl-riswoman is show¡r I week posropcratively iollowi[g a short'scar face lili'

Thc bancl cxtending from her ea¡lobe diagonally acrosstlle ncck would havc
easilybeen avoided ifthe disscctionhad proceecledposteriorly o\¡cr the stcrno'
mastoid musclc, necessitatingup"vud extensioll of the i¡cision ilr the post
aLrricularsLllcus.Howcvcr, this band rcsoh'ed sponta[coLlsl¡'at 4'"vccks

I
l
 Short Scr Fá.e Lift: Indicatiors a¡d Technical Considerariotu 59

TECHNICAL CONSIDERATIONS IN TI{E

SHORT-SCARFACB LIFT
The submental area and jawline may be improved simply through rhe sho¡¡-
scartechdque in somepatiens. In othersit is necessary to makea submental
incision for liposuction aswell asfo¡ submental contouring p¡ocedu¡esfo¡ fat
removal, platysmapücation, and deep plane manipulation as indicated. If t¡e
submental approach is required, I often con¡ect the face and neck dissection
in the subcutaneousplane to allow more even redraping and redistribution of
the skin.

Incisions
Dependilg on üe length ofthe patient'ssideburns,I selecta prehai¡lineinci-
sion or a coltiluorls incisionfrom the temDoralarea.

Tsble 2-l Choostngtbe BesrOpriolr

F¡cc Lift: Incision Options
?fcháirline With Topo!át
Discontinüous C-o¡tiruouswith
?rchairli¡c Tcmporallncision Pr€auricul¡rlncisio¡
Sidcburns

Low or long
Hairline
Anteriofl I¡teral ca¡üus to X
hairlinedista¡ce3 to 5 cm
Posterior:Literal cuthus to
hairlinedistance>5 cm
S€€ondaryfac€lift x X
ó0 \ h o r r S c ¡ rl " r c ( . L r fTr e d r n i , N c \

Ifa prch;rirlincincisionis planncd,I alsomakca scparatetenrporalincisiont<r

clcvirtcthc lrtcr¡l brow lnd to acco¡trnroclatc
thc rccruitlrcnt ofthc nticlflcc
skinthror.rgh the vcrtic¡lpull ofthc short-scar
fircclift. 1hc ¡rrchairlinc
incr-
sion is continucdprcruricularlyand intertragallyand stopsriglrt at or just bc-
hinclthc carlobc.

TEMPORAI DISSBCTION
Thc i¡cisi<¡nfirr tcngrral disscctio¡ris planncdovcr thc tcnlporalisnlusclc,
-fhe
which I mark prcopcritivelywith rhc prtient clcnchingthc tccth, incisiou
is pllccd bchindthc h¡i¡lineand ovcr the musclc,lt is nrlclcin thc tcm¡nrul
irca, with dissecti([ continuiÍlg dow¡ to thc dccp tcm¡nlrl t'irsci¡.Ovcr tlrc
clccptcmporalfhsciathc dissecti<¡rr proccedstow¡rd thc orbit¡l rim. Thc sen-
tinel vcin is idcntiliccl¡nd dissectiorrcontinues¡round thc scntinclvcin, rc-
lcasingthc ¡rcriorbitirlse¡rtaancladhcsionsto allow eflictivc l¡teral brc¡wclc-
\¡¡tioDand recruitnrcntofexcessfirci¡l skin.

UNDERMINING
Ihe ¡nrountofundcrmiringis irclividualizcd fbr eachpaticnt.It cnnbc fhirly
cxtcnsive,asindic¡tcd carlier,conncctingthc ficc a¡d previor¡ssubmentaldi"-
section,or it can bc rathcr limitecl,clcpendingon thc agiDgchrngcs.To pre-
vent thc cievelopment of a retro¡uriculardog-eirrwith the needftrr cxtcnsive
dissccti<¡rbehind thc car,I havef'<¡und that it is bcst to limit the lateralirspect
ofthc ncck undermilrilrgto the antcriorborder ofthc stcmo¡rastoidmusclc.
 Shoft Scarlace Lilr: lndici¡ionsand TechnicalConsiderarions 6l

l{etroauricula¡undc¡miningis bcst avoided.However,it may bc lcccssary to

clisscctiD thc retroauriculararcain somc individualst<¡more cff¡ctivcly i[¡1
provcon thc ncckskir1.

I¡r thoseindividualswhere it is iblt that neckskin rvoulclbe improvedby dis

sectiflgin the rctroauriculararca,I coltinuc thc disscctiolbcyondthe postc-
rior bordcr ofthc sternomastoidand superiorlyto tlre levelofthe tragus.This
disscctionsometi¡nesextends¡rosteriorlyto the occipitalhairline.This dissec-
tion invaliablyleevesa largedog-err that is eliminatedby extendingthe retro-
au¡icularincisionup to the levelofthe tragus.I havenot found it necessarl',
however.to extendthat incisionin a oosteriordirectiontoward the hairline.
\h(iÍ S.rr l:r.e I iri ln.hnúucs

SMAS EX?OSURE AND MOBILIZATION

I l)rctcr to incisc anci nrotrilizcrhc SNlA,S,irltlrorrghin sonrc l).rlrcnts,th()sc
rritlt thin firccs,I nill plicrtc thc SNIAS. lhc incisionis phnncd .rkrrrgthc
jtrrl(ll')rl,,l-llñ
) (r r . l . r r r .rl r r , , l r r S
l cl l A \

llrc sub-Str1.\S dissccti()nis rhcn iniri.rtccl.rr rhc j!rncti(nrofrhc rdhcrcnt ¡ntl

ruotrilcStrl,-\Slalrzrr').Thc tli.r¡¡on¡li¡cision is nr.rrlcin thc Sll-\S crrcrrclirg
lir¡rr thc zrqonr¡tic l)r(n¡inenccnrc.li¡lh t,rrr¡r,l thc inelc r)l rhc rr¡¡(liiilc
l¡tcr.rlh. l-hc clisscctiorr conti¡tucs¡k:nc rltc l¡rcr'¡l bol.lcr ol-flrc plitrsnt¡.
Sh.rlpdissccrionis c.rrriedoL¡tt() thc inlcri(n-lrordel t¡frhc ¡r.rrorid.ilcvoncl
lhc gl¡n(1.I prcflr blurrt rlisscctir¡rtrr ntiltil¡izc rhc lisk t() the lrr¡¡tchcsofthc
l ¡ c i ¡ l n c ¡r c .
 Short S.rr !¡ce l.itt: Indietio¡s.nd Tc.hric¡l Coi\i.1c,¡t'o.s

-v¡

Ifr'
Thc SNIASplttysr¡:r,ortccrnobilizccl,is pullccltrplvlrtl vcrticrllv.ll-ncccss.ll'v'
r p()ftiolroli!hc cLcvxted SNlAS.rndplittt'sm,r ulev bc tcscctc(1. it i\
C)lhcr\\'isc,
plicetcclrvith pcrnrlncnt st¡turc¡tretcri¡1.M,vprci'crcuccis 3_0Nlclsilcoc.(lcl
cr'¡lly,in ¡ thin tice I prcscrvcirll of LhcSNIAS;io ¡ hcevicrfice. I rcscct¡n.l
the cxccssSMAS.
cliscirr-cl
61 (h, r \.. Fr.r ,ir T!Lr¡ !t!(\

i.. ,
L/

rf,
Ncxr, dtc tcnt¡orirl lir¡tion.rnclclosurc¡r-cpcrfirr-rtrccl bcfirr.cclcv¡tion ¡lrrl r-c-
sccti()lt()f thc lircill si<in_ Su¡Ur-cs r¡f 2 0 pl)S ¡rc phccd throu¡¡h tltc tcnr
por-operictirlf'.rsciitirnd up int() fltc (lccp tent¡ror.lltiscil .rccor.rlingto prcopcr
¡tivc vcctols-This firiilliollrvill scrr'cto clcr.lrc¡ltc l¡tcr.¡lbro¡,¡ d thc ercc.,.,
l¡ciel skin titilt It¡s bcen l-ccrlritccl.A nrinintellrroLrnr ofscllp is cxcisccl.rnrl
thc tcnrpol-¡lincisionis closccluith steplcs.
 Short.Sc¡rface Lili: ¡rdicxrnnrs¡nd Tcch¡icalConsiderations

Tl¡c f¡cial slcinis then pulleclupwardin a vcrticaldirection.I havefotü¡d thirt

tlris ciircctvcrticalupwardpull, togetherwith limitcd disscctionposteriorly¿rt
tl¡c lcvcl ofthc ca¡lobe,will preventthe fbrm¿rtiorofdog earsaroundthc c¡r'-
lobe. The cxccssskin is rcsectedanclan a¡¡chorirgsutureof3 0 PDS is placcd
at the b¿seofthc cdrcha.The cxccssskinis the¡l tri¡nmcd.tailoretlaroundthe
traÍIus.al1cllnset,
óó Short-5c¿rFace.LiliIech¡iques

I plef'era trvo layerclosurcof4 0 Monocr¡,Ito thc dcrmis anclrunoing ó-0

r:rpid-irbsorbing to thc skin. I placcir clrainin all faceJif'tp|occclures.
ci'rtgLrt
For short-scrrfice liftsI ¡rlacea 7 nrm or l0 Fr driri¡'r.
Tlrc trbing is cxtcriorizccl
bchincltl'rcciulobc.L)rcssings rrc lppliccl,uc1 the patient renr:rinsovernight
in our fircility.

Preoperative
and 4-yelr postopcr¿tivc vrcu/s¡¡c shorvn ofthis u'oman wtro un
derweüta shortsc¡r'iicelif-tthat i¡rcluded
¡ sni¡ment¡l incision rvith platysme
plication.
 Sboft S..n li.. Lili: I.di..iri(n,\ rLi l c.h. i.rl (l( ¡ii Llcn¡( !is

-fhc
preo¡rerirtivc liews ol'thi,i p.llienl ,:lcnronstrlrc.rpplrcnt
cxccssski¡rin thc
suL¡ncnt¡rl -cx, j()N1s)enrl pletvsmeLr¿nc1s on ¡nimetion. Shc Lrldcrrerrt ¡
short sc¿lf'.1cc¡nd ncck lili, incLuciing e submcntelincisionl ith sut¡mcnt.rli¡t
rcnx)\'al anclpl.rtlJsme¡rlicetion. Thc posrr>pcletitcr.ict clemc¡rstr'¡tcsnccli r-c
contourin!1,implo|cDrcntof jo\'1ing,¡nrl no r-ctr-o¡ur-icul¡L sc¡r's,
ótl \h, ft \.i, I i.r I iii Trlhniq',(.

'l
his irlc:rlcl¡tlirlatc r.¡ndcrlcnt a short sc.lrfilceliti thr()ugh¡ sul)r¡cntirlin.r-
sior with sLrb¡rletysrull intcrvention, inclLrrlingplrtiirl cxcisic¡nof thc srtlr
¡r¡ndibul¡r glirncl.A klvcr licl blcphllr4rlrrswrvls irlso¡rcrfi>rnrcd.lhc post
()pcrrtivcrcsultdclnonstr¡tcsinlprovc¡1cntofthc sobnlc¡rlillilrc¡ iln(l jilNlinc.
 lr, r \.r l:r(. J.li:lr,l.ir,,r. rrl l..lr rL.r (l()frJ.i.úi(!h ó9

LIMI.IA*I.IONS
Ih¡vc lirLrnrlthrt thc linririlti()ns oi¡hc sho|t scif li(c lifi ¡fc n()t ()nl\ fcL.rfcll
tr) sliiu(lu.llit\ rn(l \Lin qLrin¡it\'.b L r ¡r l s < t¡ o p ¡ t i c n ¡ sl h o h ¡ r e h e ¡ r r t i r c c s . . r L
thLruqhhcrw I.rccs.r¡c tlillieult fcqilf(llcss()t rhc ifpf()ich Lrl incisions. tlrer
. r f cl ) , r f l i . u l . r rcl \h . r l l c ] r g i rrrrg
i t l r s h ( ) lf s c . r ft c a h n i q n c \ .

-fP>'

l his p.rticntis .rn cr.rnrplc()l lhc lirnir lirr'nrc in tcr'mso1 prticnf sclc.ti()r ti )f
¡ shor-trc¡r l¡rrccclLLrc. Shc h.rssignilicrntjorvling,rvith s o n r cs l i i nl ¡ r i ¡ c r
t c n r l i r r gp c rl r l p r I ' c ro n r l t h c t l r rr o i L lr l r t i l i r g c .F I o l c v c r ,s h c d c r r r o n s t r ¡ t c¡d
!.()()rlfcsulf.lt lS m()nth\.

.-
70 Sho.t-Scú Frce Lift Te'h¡rgues

lice
lbr e short-sc¡r txce
'."".- apDu¡f to be all ide¿l c¡lclidirtc
'r'l'i' niri¡ñr u'ho wtrtLlJ
r'rrLi l\LtLLrrLr
".'i "-,,- ' ':nlonsÚ:atcrl
:^ (l( onlv in her
¡.r oniy
-r---^-.--r",1 llot rcstllt'
rcsult' out
but
lilr- h.rs¡'or \k¡r clr\ticit\' Lllr\ rs l¡¡s Plc¡ltlng
¡ , ----^-. -i- 'Irr.-',
¡ l'c¿ .¡
o¡ c¡ch
cach side. $herc she
side' $herc she i¡¡s Plc¡ltlrlg
also in thc r'icü'of tbe retro¿urlcLll.lr
-1^"ri.ir., Thcse
el¡sticitv olcxts could trevc bcell
Th.qc plcats
,f-. t.. ii'Ot*f m a result of pool skin
sc¡r'
lloiclecl ivith e longer tettoauriculat
 S l l o nl c ¡ r F r . e T , l T r d i , r ' ,r . ' n , l T ( \ r i . ¿ . o l . d c a r i o ¡

ALthoLrgh this woman presentsan acceptablcrcsult,I bclicvethat in a patient

with a heavyfaceand necksüchasthis, I would havebecnablcto sccurea bet
ter resultwith the ñlll-sca¡facclift.
Shorr-Scr Face üft Techniques

It is in the patient's best interest to focus more on thc quality of the result
rather than the length of the scar.Minimizing tl¡e scar while compromising
the resr¡ltis not in thc best interest of thc patient or surgeon.U¡less the result
meets expectations,the incision lcngh is immaterial. As in all plastic surgery
operations,carcfiJ patient cvaluation is kcy to idcntifying the appropriate can-
didates for a short-scar procedure. For short-scar face lifis I believe tlte single
most important factor in patient selcction is evaluatíonof skin quality and skin
excess.

COM?LICATIONS AND RBOPERAIION

I haveseensignificandyfcwer hematomaswith the short-scarface-liftproce-
dures:0,5%comparedwith I% to 1.5%with a full-scarfacelift. This I believe
is relatedto lessextensivedissectionwith thcseoDefations,I alsohavenot haq
anypermanentIreryeparalysis.

In my earlyexperience,dog-carsand plcatsaround the ea¡ were not uncom-

mon; some required rcvision. I have not had to ¡copc¡atc on any of my pa-
tients to improvc thc result. I an¡ibutc this to carcful parient sclcction with
panicular anention to thc skinl

FINATTHOUGHTS
Short-scar and minimally invasiveproceduresfor facial rcjuvenation are herc
to stay.Thc dcmand is driven not ooly by media hlpe and exaggcratcdclaims
in advertisir¡gbut most of all by patient demand. Thc promisc of litde or no
scarring, minimal down time, and litdc or no risk is very tcmpting to all pa-
tients, regardlcssof\Mhether they arc suitablc candidarcs.It is thc difncult task
alld responsibility of the surgeon to cxplain to such parients if they are not
suitablecandidatcsfor tie proccdurc.Wc shouldknow the ümitationsof our
operationsand must neve! shy awayfrom informing ou! pade[ts, evenif we
risk losingthe patientto the next surgconwho mayperform the procedurere-
gardlessofwhether it is in the paticflt'sbestirte¡est.

Merelyreducingor eliminatinga scaris not an advanceor an advantageunless

the resultsmatch o¡ aresuperiorto thoscofstandardprocedures,wiü sirnilar
or reducedmorbidity.With appropriatepatient selection,the short-scarface
lift qualifies assuch an advancc,with dcfinite advantagesfor our patients.
 Sbort-Sc.rFá.c Lift: Indicationsand TechDicilConsiderátions

BIBLIOGMPTry
Ansaí P Eliminationof r€troauriculer incisionin facclifts. AestheticSurgl23t14-19,
2003.
BakerDC. Minimalincisionrhytidectomy(shortsc¡rf¡cc lift) with lateralSMAscctomy.
Acsthcric SurgI21:ó8'79,2001.
BakcrDC, NahaiF, MassihaH, TonnardP Shortsc¡rfacelift. AestheticSurgJ 25ró07-
6 1 7, 2 0 0 5 .
BostwickJ III, E¡vcsFE, Nnhni¡. Endoscopic PlxsticSurg€ry. St Louis:Qu¡lity Medical
Publishing, 1995.
EavesFE, NaheiF, Bostwick.l lll. Thc eodoscopic rcck lift. Oper Tech PlastRcconstr
Surg23r599,1995.
Imbcr G, S¡lichRC. Limited'incisionfacclift rcchnique.AestheticSurgJ 2l:216-22o,
200L
NahaiF. Clin¡celdccision-making ¡n faccl¡ft xnd neckl¡ft. In NehaiF, ed.Thc Art ofAcs-
theticSúrgcry:Principles & Tcchniques. St Louis:QualityMcdicalPublishing,2005,
p 897.
'fhc
NahxiF. Nccklift. In Nahail', ed. Art ofAcsthcticSurgery:Principlcs & Tcchn¡qucs.
St Louis:QualityMcdicalPublishing,2005, p 1239.
Tonn¡rd PL, VcrpaclcAM. The MACS-Lili Shorr-Scar Rhltidectomy.St LouisrQuality
Medic¡rlPublishing, 2004.
Tonn¡rdP,VcrpaclcA, MonstrcyS, ct xl. Minim¡l ¡cccsscrx¡ialsuspcnsioll lift: A Dlodi-
ficdS-lift.PI¡siRccoDstr Surg109:2074-208ó. 2002.
 ^ t'\
A Svstematlc
Approachto
MACS-Lift Operative
Techniques
Joscphl). I-lurrstltl

75
short Sca. Face Lift Techniqrcs

.T-
Ihe or:tcone of f¿cialaesrhericsurgerydependson preoperativeplarning,
operativetechnique, and precision. It is highly desirablefor a patient to ¡eceive
the benefitsoffacial rejuvenation without t¡e unwanted stigmata ofsurgery. A
dedicatedaestheticplasticsurgeonwill commit to performingaestheticproce-
duresüth great care,delicacy,a¡d p¡ecision.A properlydesignedprocedure
suchasthe MACSlift allowsoptimalfacialrejuvenationwith avoidanceofun-
desirablefacialchangesthat indicatetiat surgeryhasbeenperformed.Com-
plete elimination of the postauricular scar is fundamental but was not always
availablewith previousshort-scarfacelift techniques. The impressiveimprove-
ments in the midface,cheeks,and remarkabl¡ the neck are hallmarksof this
impressiYe technique.

Thus a revolution has occurredin facialaestheticsurgeryusing procedures

suchasthe MACS-Iift, wherewonderful full facialand neck rejuvenarioncan
occur with minimal morbidity and a dramaticallyshortenedrecoveryperiod.
This minimal recoverytime is an essentialand attractivecomponentof the
procedure.This goal can be significantlyenhancedusing proper infiltration
techniquesandfrnemicropointelectrocautery to truly eliminateintraoperative
bleedingand, for most patients,reducepostoperativebruising.

EVOLUTION OF TECHNIQUE
Over the yearsancillaryprocedureshavebeenaddedto the MACSJift to pro-
vide a more enhancedfacialrejuvenation.Liposculptu(earrdco$et platysma-
plastyare now routinely combinedwith MACSJifting, and the third suttre
hasbecomea routine additionfirr patientswith midfácelaxity.

Becauseof theseadditions,indicationsfor dle MACS-lift haveexpanded.In

my practice,úe MACSJift, in combinationwith ancillaryproceduressuchas
neck contouring,is capableof deliveringexcellentresultsto the vastmajority
ofpatielts seekingfacialrejuvenation.Patientswith p¡ofound neck laxity oc,
casionallyrequire a direct neck lift du¡ing facialrejuvenationprocedures,but
this hasbecomefairly unusual,

INDICATTONS/CONTRATNDTCATIONS
When I beganusing the MACS-lift fo¡ facia.lrejuvenation,I believedt}re proce
dure was indicated for relatively young patients with minimal neck laxity. As
experiencewas gained with this procedure, I ¡ealized the true power of the
üfting, and beganusing the technique for patientswith greater degreesofneck
larity ard ñ lness,with excellent ¡esults. Patients with excessneck adiposity
alrd laxity have rema¡kable ¡esults when concuffent neck ]iposculptr¡re and
 A s-vstem¿ricAppro¡ch io MACS Lift Operative Techniques 77

co¡setplatysmaplasty areused.Centraland midfacemalardescentis significant-

ly improved when the thi¡d suture is incorporatcd. As experiencewas gained,
the addition of this third suture was shown to add minimally to the operative
time and significandyto the improvementofdre centralmalarregion.

The MACS{ift is alsoan excellentoption for secondaryface-liftpatients.Pa-

tientswho havehad a previousfacelift are amazedat how rapid the recovery
is from the short-scarprocedureand how impressivethe rcsultsarc.

Patientswith severenecklaxity,in my hands,representa continuingchallenge

for the MACSlift technique.Usuallythesearepatientswho areolder,witi sc-
vereenvironmentalskin damageand occasionally massive-weightJoss patients
who haveachievcdtheir targetwcight. Othcr than this selectgroup ofpatients,
the MACS-lift hasprovedsafeand highly efflctivc in trcating thc majority of
patientsseekilg facialrejuvenation.

OPERATI\,IE PROCEDURE

IQy Elernents
. Full facialand neckinfiltration is performed,simila!to the infiltration
method usedfor liposculpture.
. Blunt-tippedinfiltratior cannulasar€ usedto eliminatebleedingdur-
ing infiltration.Thorough irflltrarion is performedwith epinephrine-
containingfluid that significandyexpandstissuepla[es,magnifies
theseanatomiclayersarldmakesthem more distinct,and promotes
profoundvasoconstriction.
¡ Infiltration is performedin a pressurized fashior, infiltrating approxi-
mately500 ml for the full faceand neck.This pressurized fluid exsan-
guirutesthe facialtissucs,allowingthe epinephrinesolution to be-
come maximallyeffective.
. Lidocainewiti epinephrineis injectedusinga 25-gaugeneedleand
syringe into t}re dermis along the incision liuc. The irrcisiorrcarrthen
be madewith ürtually no bleeding.
. The ñne zigzagincisionis madewith a scalpelinto but not com
pletelythrough dre dermis,perpendicularto the hair follicles.This
protectsthe subdermalplexusso the incisionline doesnot bleed.
. Electrocauteryusinga Coloradoor equivalentmicropointtip is used
to completethe incisionthrough the dermisand for all subsequent
dissection.This virtually eliminatesbleedingthroughout the proce-
dure.
78 shon-S@ Fac€-Lift Tcchniqucs

Key Elene*fr---+ont'd
. The superficia.ltcmporal vesselsare identified ard ligated, eliminating
this potential site for postoperativebleeding.
. Dissection extendsanteriorly, closeto thc nasolabialfold to allow the
'O" suture (asdescribedby Saylan)to be maximally effcctive for thc
inprovcmcnt of this area.
. No &essings a¡c applied for patiens who rcmain ovcrnight in our
facility. This allows carefill inspection oftle surgical sitc by thc night
nursing staff For outpaticnts, a light compressived¡cssingis appüed
that is rcmoved the following day. Pcnrosed¡ains are ¡cmovcd on
postoperativeday l.
. Our ancsthcsiamethod of choicc is a gcneral ancstheticprovidcd by
out ancsthcsiologist.Occasionallywc pcrform thcsc proccdurcs under
local ancsthesiawiü sedation,which is also highly effcctivc. Because
of tllc profound vasoconstrictionachicvcd by ou¡ method ofinfiltra-
tion and clcct¡ocautcry disscction,vasodilation sccondaryto gcncra.l
ancsthesiahasnot had a det¡imental effect on intraoperative bleeding
or postopcraúvcbruising,

Markings and Incision Placement

Patients are carefully photográphcd and marked preoperativcly.The decision
to perform a prehairlineor scalpincision is made preoperativelyand is dis-
cussedagainwith the patientbeforesurgery.This decisionis madeby strongly
elevatingt}rc prcauricula¡skin at the sideburnleveland noting the degreeof
hairüncelevationachievcd.If thc sideburnis long and thc hairlinc low (un-
usual),thcn thc scalpincisionis uscd.More oftcn, howevcr,this maneuvc¡elc-
vatestie sidcbu¡n cxcessivelyand the prehairline incision is used. Preauricular
markings arc madc in a retrotragal pattern. The lower edgc of the jawline is
oudincd, asis the extentofundermining.

A point 2 cm bclow the latelalcanthusis markedasa point offixation a¡d el-

evation for thc midface using the third suture. The undcrmining takes ttris
point into consideration aswell as the fixation point lateral to the orbital rim
for malar suspcnsionto the deep tcmporal fascia.
 79

-:tf

YI ., \_,,,/

t \rr
j'{Pr
fl0 slx)r 5.r Fr.. l.iii l..r¡i(tL,rs

Anesthesia
\,lost ol'our p:rtientsch<xrscr¡cncr¡l ¡ncslhcsi.r.I-ocrrl¡ncsthcsi¡ rrith scdttion
is ¡ rc¡son¡lrlc ¡ltelniti\ c thilt s()ntcpillicnls rcqrrcst. llcgirrtllcssofthc nrcthod
choserr.oncc sctlirtioll ()r iurcsrhcsiilindLlction JrrrsoccLrllcrl,loc¡l infil¡r¡rion rs
. \ ' ' ; , r r r c r .l r ' i I | l , , f l s r . . r . i . l r ,1l . . . . l i l i r ' r r r . r .

Hunstad Face-LifLInfibratiott I.orruula

Nor'n¡l sirlinc 500 nrl
l% [,irirc¡inc 50 nrl
F . p i n c p l r l i r lr:c1 0 0 0 I nrl
I(crr.rl0c,l0 Inrl
l( \t, 552 rrl (crrorrghfiu firll fircc¡ntl nccli
irrtiltf¡tion)

-
,lw,'
,t: ,(

I n l i l t f i l i o r o l l o c ¡ l r r c s r h c r i c{ 3 0 0 r t ¡ 5 0 0 r r r l )i s r c l v i r r r p o r - t . rrnr ü t cnpcr
1i)rrnirrqlhc "clectlic,\'lr\(lS liti." licc¡rrscclcclroc.rLrtclr is Ltscrlthr-oLrrthoLrr
l h c c r r f i f cp f ( ) c c r l u r c¡ h. (r'()ugh i n l i l t r ¡ t i o ni s v . t l L r ¡ b b
l cc c l u s ci t c r c . r L c sh. r
rlr'¡tc,:l suLrcu¡¡rrcotrs cnr irol¡llcnt rvith rlistincts()frfissocpl¡trcs¡ltl rlcsiI-Lrl¡-
\rs().()nslri.ri()r.l hescpl:rncsllc crrsilvlisu¡lizcd ¡rrd ¡lLll clcc¡lrrclLrtcrv..,
bc Pcr-lirrrrlctl \itlroLtt ¡iffi.Ul¡v.Thc ltr'drillcLltissLrc is ¡ls()c\trcnlclv clfccrir.
bv pror idirrc r crxrlinsrnctliumso rh.r1lissuchc¡tinq docs not oceur'.l:lcc¡lsc
clcctrocrLrtcr v plor itlcsI tlLrlvbkxrrllcssliclcitl¡¡orrr:lloutthc [¡r'oecr]urc. rhcr-c
is rir'¡Lr¡llvno bluising ¡ostopcr.rtir clr ¡ Lreltcfitcnthusirrstic¡lli cntbr¡ccd bv
rll 1-eticnrs.
 A Sysre¡raiic
App¡o¡chro IÍACS.Liti Opcr¿tiveTcchniqucs 8l

Tbc im¡rortantplancsofdisscctiollovcr thc platysnail¡d orbicul¿risoculi are

clcarlyvisullizcclusing this approachas will bc dcmonstratedsul-rsecluertlv.
Thc incisionlinc is injcctcdsuperficiall¡,,irnmedirtelybelowthe clerrlisto ¡rro-
lidc ¡rrolhrrrrlincisionlirr r.r.oionrt¡irtion.

lf enclotrachc¡l intubation is pcrforncd, thc endotrachcal tube is secrued to

thc carinc tooth with dcntal flc¡ss.lvhich does not distort sot'i tissuestlllcturcs
ancl is vcry sccu¡c. Thc cycs:rrc protcctcd rvith ophthllmic ointment to pre-
vel1t drylcss durilg thc proccdurc. Carcñll pleprrrtion and dr:rping are then
pcrforrned, '"vith the drapes usually secLl[edwith silk sutLlfesto pre\¡ent dis
placement.
a2 Shorr-Sc¡rEJceUÍi Techniques

Technique

The prehairlineincisionis madewith a No. 15 bladeperpendicularto hair fol-

Iicles in a tight zlgzag pattern. This approach permits hair gro*th to occur
postoperativelynot only through but alsoin front of the incision li, e.
 A S\'\rcNiticAppr)¿.h to ivlA(lS.l.iti ()pcri¡ne Tcchniqucs 83

l)isscctiol'lis thcn c¡rricd to thc sutrcutirlcousfht. Thc skin ovcr thc trlgus is
usuirll¡'clcyntcd s,ith clcctroc¡utcr!,ifit is nrobilc,or rvith cr.rrverl
iris scissolsif
ir is ¡clhcre¡rt.

Iilo¡r this point filnvard, the c¡¡tirc disscction is pcrfbrmed r.rsingclcctrrr

crutcry \\'ith ir Cok¡r¡clo micropoint tip, This fine insulrtccl pinpoint do'icc
permits prccise irncl clclic¡te disscction to protcct and prcscrve mlximum flLr¡r
virsculilrity,n¡i¡t¡in disscctioll sqrcrficial to thc SMAS protcctil'lg it ir¡d thc
f'aciirlnerves, urtl pcllbf¡n flap cleviti()n in cractl)'thc cor¡'ectplanc.
84 Short Sca¡FaceLift Techniques

Dissectionis performedinferiorlyuntil the fasciaofthe platysmais identified

at üe angle of the mandible.To identi$ the critical fibrous portion of the
platysma, dissection may need to be performed up to 2 cm inferior to thc
mandibula¡ bo¡der. The dissectionthen continues anteriorly over the musclc
itselfalong the jawline.Once the fasciaand muscleare seen,the dissectionis
vc¡y safc, with facial planes clearly evidcnt, magnified by the hydrated tissue
plane separationrcsulting fiom iniltration. The muscleis clearly seenseparirt-
ed ftom the overlying fatty soft tissu€s,and dissection is perforrned immedi-
ately supcrficial to the muscle. This ensurespreservationand protection of all
ofthe soft tissueofthe face as well as the accompanyingblood vesselssuper-
ficial to the SMAS.Thus the most vascularized and ¡obust facialflap possible
is Dreservcd.
 A S!stematicApprcachto ItrACS Lih Opcr¡tiveTech¡iques

,-\t

I
86 shoLi Sc¡r f.r(e Liri l¡ehni(tL,cs

l)isscctionis thcn pcrfirrnrcrlsu¡rcliorlvuntil thc lirtcrirlcdge ofthc ()rbiculilrrs

ocLrli¡¡r¡sclcis scc¡. (lirlc is t¡kcn to ¡voirl unrlcrminingthc orbiculir¡is lrYtlis
scctiDltt(x) clccplr';to:r\'()id this, \!c rcc(rnr)lcndtiisscctingtiircctlYto this
()ncc this point is rc¡chcd,disscction()\'crthc rirusclcis srrdightti)f\\¡rd
¡roinr.
bcc¡uscofthc h),dftrtcc] strtc ¡chicvcdbv rhc Ircirl ¡ncsfhcticinliltrrtion. l'his
is:r vcn sefl pllnc lrccauscit is sultrficirl t<¡thc ¡'t'lusclc.
 A Slstcnr¡ticAppft)¡.h ro MACS Lili ()pcratiycl'echniqucs a7

O¡¡cc the fi¡ll cltent of the disscctio¡rover the infcrior poltion of thc orbicu-
Iaris oculi is completcd ard the dissec¡ion over thc superior portion of the
¡rlatysmahas bccn achicved, thc intc¡'veoiDgtissue can be clcvated s:rfily irt a
lcvel dc6ned bv these nvo Do¡nts.
88 Shor¡ S.¡. ¡¡.c Lilr Tcch¡ntucs

Alter underninirrg, I crrclully sprelcl the tissue I cm allteúor to thc incisior,

jLrst cephxlic to rhc zygionatic a¡ch lüich is outlinecl rvith mcthylcne bluc.
I
coDpr-cssthis ercl with mv thurb to displacc the infiltf:rtion flrLid so I can
cle¡flv visu¡lizc the supcrlici¡1tcmponl \,essels
aud acculttely idcntify thc zygu
¡D¿tic ch.
 \ i r n " , ' r .( A t t , o - l 'l\lq.(l lof.1r'\JT.l-'.,1''. 89

I usc finc-tippccl Mctzclbaun scissorsto spreadthe tissLlecephahcl to tl'rc z¡

gon¡tic irrch to visualizc thc dccp tcmporal fascia.The superficial temporal
vcssclsarc visualizcd and lis¡tcd or cauter-izetl.
90 \hi¡r S.rr I r.r I rl1 li.|'i\tuL\

i\n0Pl)S\ulLrfclirltr¡ncnor.lII)l)Ssuturcfi)llllen\\ilh.lstr()ngtipcfc(l
nccdlc is u\c(l lirr thc suspcnsion5r.rturcs.fhe first su¡ulc is Pl¡cctl dircctlv
postclior-hils sUggcslcdb! Tonn¡r'rl.rrr(lVcrl).rclcln,:l lhcn sLrtrrrcd in ¡n in
tcrmptc¡ pLrf\csling lishi()n tlircctlv inl.rrir¡-to thc inrl)()ft¡rrllisci.rol'tl
p l i l t r s n l r t r h c x n ! ¡ l co l t h c n r ¡ n c l i b l cl.h i s ¡ l r i n r r > f h x . r t i o n h ¡ r L ) c c n d c n r ( ) n
itr¡tcd clc¡rli bl l..rLrlrc ¡r bc thc nrost cflcctirc ¡roint ol Pl¡tlsnr.rfl¡fr clcr¡
t i ( ) nt i ) f r r c c l c( ( ) r l l i ) u r i n(ss e c( l l ¡ . r P t c r ' 7 1 .s. \t r ' o n gh r . r t i o ni s ¡ c h i c r c r ¡l t t h r r
¡oint.rntl thcrr thc l)r.rrsc strinSsuturc(('ntinucsvcrricirll\.alc¡linr.¡.rrcl.rti\c
lv n¡r'r-orrLl sh.r¡rcrl srrtLrlc.
 9l
,\PPro¡chto M'{CS'LiR OPcratireTccbnnlL¡es
A S-vlte¡raric

I
92 \ rli r !.r lr.. lit¡ l..r¡i.trr\

.;F*-.:^"'
\..6-
,

I l r e s t r o r r q l i l i i r g o lt h c n c c l i i r e l c ¡ r ' l r c r i c l c n t r i t l r r L r ¡ u l c l r g , h t e nl lrrrcgs.
f L r r e¡sr - ct i g h t c n c rrle l r r c c r r r e l.rr r i l t i c r lr r i t l l l i r L r r - s q L rl.iur r-oc t s .

'I
l l c s c c ¡ r n Js L r t L r r r- h c .e ( ) s L r t r r r -i cs .r l r c n ¡ l l c c . l . I t b c g i r r rj L r s ¡t n l c f i ( ) r ' l ( )t h c
h r s r l i n o ¡ . l h i s s L r t L r rc-rcr L r r - si cr lsi l i o r ' l r . ¡ ¡ ¡ n l l c l t o t l r c L r s u t L r l cL r n t i tl l r c c L l ! . c
o l L h c n ¡ ¡ n t l i t ¡ l ci s l c ¡ c h c i l l h i s p u l s c r t l i n r s r r l r r r c c ( ) r l t i r l u r s r l ( ) n ! l,h c c L l g r
. e\1. it (()r)li
o l t l r c l i t i . r l l l , r ¡ r r r r t l c r r r i r r i n¡gn t c r ' i o r l v¡ n r l r h c n s L r l c f i { ) r l \N
( ) l
r u c s¡ o s t c l i o l l v t o c n c o r r ¡ . r s st l r c i r r l c r i o r1 ) ( ) f l i ( n r t h c r ) r L ) i . t r l . r loi sc L r l .i r t t h c
l c v e l o l t h c t i l s ¡ l < n , r ¡ .l l r c s L r t L u ci r t i c r l t i g h t l v , . r c l j ; r c c nt LLr t h c f i l s t r r r r L r r . .
\ r t h t i r L r r - s q L r .l ri f| ¡cr t s . . ' \ . 10 \ ' i c r r L s u t L r r ics L r s c dt o c L r s ct h c s ( ) f r¡ i \ \ L r c( ^ c f
¡hcsc tlo LrLu-icrl l(no¡s t(r pfe\crrt I).rII).rbiIiI\.
 ASystcmatl.Approachto I'I-ACSl.ift Ope.¡tiveTechniqucs 93

Ioitiall¡ I would placeboth the U and O suturesand tie them together,not

seqlrentially. However,I found that this approachwasnot aseffectiveastyir-rg
the sutLrres assoonastheywereplaced.Thus the U suture,when tightenedef-
féctivel¡ lifts the soft tissreto a givenpoint. Additionallifting is ther achieved
by placing the O sutlrreand secu¡ingit. I believegreaterlifting is acl-ieved
with this latter app¡oach.
94 Short-Sc¡rf¡(c Lifi lirhniqucs

'l'hc
thirclsutr,ucis thcn plircccl.l'he pointoffir¡tion is tlrc clcc¡rtcm¡ror':rl firs-
cia just lltelal to the orbit¡l rim at the lclcl ofthc uppcr linrbtrssu¡rcliolto thc
-fhc
I¡ter¿rlcurthus. Mctzcntrrur¡ sciss()lsare uscd to s¡rrcaclthroulih thc or
bice¡liuis oculi it this point p¡rdllclto thc nLrsclcfibctsto re¿chdre.lccp tcnl
poral firscin.Pl)S strturc is thcn plirccclsccu¡cd to t¡1erlccp tcr)1porirlfirsciirirt
this poiút, irncltfrc pLrrsc'string sutureis dircctcd to thc soli tissucs¡r e lcvcl
'l
2 cnr clircctlvi¡terior to the lirtcrclc¡r)thus. hc suturc g¡'¡spsthe sofi tissuc
lncl c<¡rrcsbirck to thc point ofoieti¡r irt the clccp tenrP(rrrl tirsciir.This ¡ruÍsc
stnn!! sutute ¡s vcrl nilffow,
 A Syrcñ¡tic Appuch io ITACS Lilt Oper¡dlc Tech¡iques 95

Next,4-0 Vicryl suturesarc usedto closcthe soft tissucover tltcseknots ro

prevcnt palpability.The undersurficeof the sl<infl:rp is ius¡rectcdto cnsure
perftct hemostirsis.Any bulgesthat irrc crciltedby the U and particululv thc
O snt[¡cs arc trc¡tcd u'ith clcctl.oclesicciltioD
¡nd dircct rrimmiirg to clintinatc
.u)y bulgc or füllDesstitat, although tcmporar¡ can be clisconccrtingfbr tl.rc
prricnr.

Sincc2005 my suturcof clroicchaschaDgcc{ t'i.oml ¡rcrm:rncnt prolcncsu_

tulc, whichrcqrrirccl mrry ktlots,to dn ¡[rsorLr¡blc 0 pI)S sutn¡cfbr womcn
anclI PDSsL¡tltlcfbr ntcrr.Thc rcsr¡lts.rrcntii[rilincdctluallyfirr thc ¡rclrna_
ncnt aswcll ¡s thc tbsorbiblc sutlu.c$)
suggcstiugth¡t rhc intbricati(n ¡rcirtccl
by thc absorbablc sutureshcalssccur.cly bcfbrethc timc oisr.¡turc dissolutiou.

The undernircd arca is thoroughly irñgetcd ltith sirlinc so[Ltiot to remove

any p¡oducts of electrodesiccatior-r
and cjcbrisLreforcclosurc.
96 Sh(nt S!.! F.¡.. l-,lLle.h¡ntücs

l)cnroscrlrrrins.rrc pl:lccdthfough ¡ snr¡llstirl)iocisi(min thc post¡r.rricul¡r-st¡l

cus. (l.rfcfirltrrnnclinginflrior to thc cirf cdftilirgcis rlt¡rc. Horvcvcr-,thc r¡:
gion ol rhc cerl¡rbcsl<inis lcfi untor¡cllcclLrccirLrsc it rvill rcquilc subsc(lLrcrlt
iitljurstnrcnts.Il'¡ corsct plilt-\¡sluilplilstl'(n-nccl(
liposcLrlpfLrrc is pcrtófmcd,.r
7 nrnr lircl<sorr ltr¡t¡ dr'¡irlis usccl.I)reinsrrrcusullly rcnlolcd thc rrr()rningilf:
tcr rhc proccrllrr-c.
\ 5 1 \ L r¡ ¡ \ \ f | r , ) . t r r r ¡ ) ¡ 1 1 ( S I r i ( ) t . r . r r j \ . l ( . ¡ r i , l r . \
97

' %'-.1%i

1r{lrlcr)lltq
98 short Scd Face Lift Techniques

Demarcationis performedat this point, and, unlike oüer face-lifttechniques,

th€ vector is truly vertical, as emphasizedby Tonnard and Verpaele.Using an
Allis clamp,thc facialskin flap is elevatedverticallyand demarcatedusingspe-
cial Trident scissors.The point is securedwith 4-0 nylofl.
 A SvsemrticApproa.hio MACS-Lili OpcrativeT.chniqucs 99

This maneuverresultsin an upward distortiol of the earlobe,which is easily

addresscdby r.eleasing thc earlobewith a backcut incisionar tlte bascof thc
eariobethat allowsproperrepositionilg.UsiDgCoDnell,sconccpt,rhc e¡rlobe
is positionedol a line l5 degrecsposteriorto the mandibularborde¡.
100 Sh().l Sú. F.cc Liti Tc.h¡ntL,Ls

Oirrcful m:rrkings firr skin tlimnring arc therr ¡rerftrrnrcclso thtt the exccsstis-
suc is remoYed¡¡rciclost¡recan [r ¡chicvcd rvithout tension to crcatc a fine lirrc,
lrigh-qrrelin'sc;rr Thc plctragal tissrrcis dcfirtted using thc cur'\'cdiris scissors.

'l'hc
tr'rgusmust l-rcshapcc{ in ir vcrv acutcfirshionto ¡voirl l¡lr¡ntin€iofthis inr-
-fhe
p(t't¡nt ¡rl¡tonric f¡¡trlrc. iñport¡ncc ofthis shirpingrvirsirritir'rllydcnron-
strirtcdt() D]c b,vHcstcr when I visitcd hin in 1995. lilrrutil]g ofthc tr¿lilrs
nrust bc ¡\()idcd to climinatc tellt¡lc cvidcncc offi¡ciirl srrrscrv.

Olosulcis perf'<urrrccl rvith inter'ru¡rtccl

6 0 Prolenesutufcson cachsideofthc
tr:rgüsand then ir rl ]uing, everti[g pilttcrn with 6 0 PÍolcnc firr fil1alsl<incl<r
su¡'c.This suturc linc is tcnsioll frcc.'fhis running P¡olcncsuturc is ticcl.rs¡n
intcrruptedsutr.rrc irt the root olt¡rc hclix ¡s a fixation¡rrint. l his sr¡turcis rc'
nrorccl on thc scrcndr postoperativc d.r¡,.The runnilg slltLrrcsarc usuallv rc
nrovecl5 dlvs postopcmtilelr'.
 A System.ticApprcachro MAcS-Lift opehtive Techniqúes I0l

Postoperative Care
In the opcratingroom, the facea¡d hai¡ are carefullywashedto removeany
traceof blceding,which is usuallyminimal. Bacitracinointment is applicdto
the incisior lines.Ifa corsetplatysmaplasty
hasbeenperformecl,a Stefi-Strip
bandageis appliedove¡ the chin incisionfor securiry

Often thesepatientsspendthe night in our recoverycentermonitored by our

nursing staff. In this sctting, no dressingsarc applicd.Thc ovcrnight nurses
cancarefullyevaluatethc entirc faceat,tdneckfor anysignsofbleeding or vas-
cularinsufficiency. It shouldbe noted that postoperativchematomaand/or s-
chcmiahasbecnvirtuallynoncxistent.

For outpaticnts,a light hcaddrcssingis appliedandshouldbc very light, allow-

ing visualizationofthe cheeks.Patientsare usuallyexamincdon postopcrative
day l. Drains arc removcd and paticntsarc allowedto bathc and shampoo
thcir hair.Slrturclemovalis peformcd incrementally. At 5 or ó daysvirtually
all suturesare removedexceptfor an intcrruptedsuturcplacedaboveand be-
low the tragusand at the root of thc helix. Thesethree sut[res ffe thcn re-
movedon postopcrativeday 7 or 8.

During the earlyrecovcryperiod,our paticntsare scenby our skin carc spe-

cialistsfor gentlc manuallymphaticdrainagcand facialand rreckultrasou¡rd,

COMPLICATIONS
Complicationswith this procedurehavefortunatelybeen rare.Slight irregu-
laritiesbencaththc skinwhercthe O suturewasplaccdwcre a probleminitial-
ly but havcbeenaddressed by electrocautery
desiccationand uimming ofthe
areasoffullnessbeforeskinclosureaspreviouslydiscussed. Ifthey persistpost-
opcratively,they should resolvewith time, facilitatcdby externalultrasound
and massage. Ifthey were to persist,conservative injectionsofdilute stcroid
suchasKcnalog-10may be considered.

Sl¡ould ischemi¿occur, particularlyin heary smokers,thescareasshould be

left to demarcateon their own with conservative
managementusingantibiotic
ointment and conservativedebridemc¡rt.If hypertrophicscarringoccurs,rt
canbe managedby eithcr intralesionalsteroidinjectionor scarrevision.

One ofour patielts experienced

a sharpsnapin her right cheekduring the first
weekafter surgery.Shedcvelopedsomelaxity at the mandibularangleand it
wasassumedthat the ProleneU sutu¡ehad broken.This requiredrcplaccment
ofthe suture,which wassubsequently perfo¡medwith a satisfbctoryoutcome.
LO2 Shor.Sc¡r Fice r-ift Techniques

RESULTS
The resultsfollowing MACS-lift are tmlf impressivc.I shares'ith mv patients
that this is a relativelysmallprocedurcrvith largercsults.In fáct, the results,
particularl-vin the ¡cck, arc gre¡ter thaDonc u'ould expcctfiom a short-scar
vcrticalfacelift.

CASEEXAMPLES
AestheticAnalysis
This 3S-year-oldwomáo requestedfbcial rcjuvenationbccauscshe fllt shc
looked tired. Shedislikedhcr earlyjowl formation, midfhcialdescent,promi-
nent nasolabialfold, and earlymariolette line ficrmation;shehid alsolost thc
deñnitionofher jawli¡rc.Sheundenvcnta MACS lift undergcneralanesthesii
asan outoatient.

Nons*rgical Plan
Thc treatmcntco¡'rsisted
of:
. Skin cár€rrcatmcntwith Rerir-A bcginning40 dayspreoperatively

S*rgical Plan
The treatmentconsistcdof:
. An extendcclMACS'lift
. No blepharoplasty
. No ricckprocedurcs

Postopera,tip e Raru lts

For this young patienta wondcrfulvolume restontion to the upper and mid-
ficc is seenasu,ellassigrificantimprovemcntofthe neck.Iarvli¡redcñ¡titionrs
dramaticallyenhanced.Significantnasolabialfold improvementand elimi¡rc-
tion ofmarionettegrooveshasbecnachieved.The prchairlineincisionis trull'
invisiblethanksto the zigzagconfigurationand strongbevelingperpendicular
to the hair fi¡lliclcs.Skin laxiry earlyplatysmabanding,and lackofjawline de-
finition canall be corrcctedwith this proccdr.rre,primarilybecauseofthe vertr-
cal lifting provided by dre U sutureas it graspstbe firscialconrponclttof the
platysmaat the mandibularanglc.
 \\,.,,r.LL. ift. r,. \L\r: ()\ i,! l..,,tL,r l().1

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t
qt
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 104 Shorr Scrr l¡ce Lili ltchóigu€s

Aesthetic Anolysh
This 48-ycar-okl *oman requestcd ficial and ncck rejuvenatiolt. Shc had ficial
Iaxitv with soft tissue dcscent, ancl ncck llxity arrd exccssadiposiry rvith cauy
jowl ÍbrrD¡tion. She tvisheclto utinimizc clou,ntime vet havc significlnt in-
prove¡rcnt ofthe neck \\¡itltoLlt ir postiluricular incisio¡1.

Nonsurgical Plan
Thc treatmenr
co¡sisred
of:
. SkincaretrcarmentrvithRctin-Abeginning45 daysprcoperativcly

Sargical Plan
The trcatmentconsistedof;
r An extendedMACS-lift
r An upper blcpharoplasty
. Submental liposculpt[¡rc
. A lowcrlid pinchblcpharoplasry

Postoperatiye Res&hs
This p¡ticnt is shown ¡pproxint¡tcl!' 5 7: nronrhslftcr surgcr¡,.Significlnt int,
¡rrovcmcntofthc nridfirce,jarvlinc,r¡rc1ncck is notcd. A vcry n¡ccrcsto¡.ffi(rr
of:miclfhci¡¡lvoh¡ntchasl¡ccr.r¡chio'cd u,ith rhc rhird surur.c,¡n<lthc ficill tri,
anglcofyourh is rcstorcd.The ficirrltrianglcofyouth is sccnm ¡ sct ofli¡cs
fiom thc chcckro tltc jawliuc.Facirrl llxity ¡ncl clcscentoccurrvith timc ¡ncl
thc tri¡nglcofvouth changcs to a r.cctirnglcofaging.The prchlirlincincisiou
hcrlcdlrcautitirllyanclthe prticnt hrd no tclltrlcstigmata ofhavinghrclI ¡.rr.o
'l
cccirrrc. hc Connclldorvtglzirrgv¡cwdcmonstratcs thc dr¡maticirtrpf(\.c,
Drcutin ncckslt¡pc and contour.'l'l.rccyclirlsh¡r'e a be¿t¡tiñrlyouthlirl .r¡.r¡.rcirr
¡ncc ¡r'rdthc hooding presenrp¡eopcritivclyhasbcct eliminated.Thc cr<¡rv's
flct h¡r,ebccn lessclredas¡ rcsultofthc third suturcand true vertic¡l vcct()r()f
thc lifting.For a middle-agerl p¡tienr,$,irhgrcaterrcck laxiq,andrdi¡rosin,,
jo* ls, irnd prominclt lasohbill fblds, thc MACS-lift in comtrinatiorrrvirn
submcntalliposculptureoftlrs ¡ rvolrclcrfülo¡r¡nrtunitl,for correcti(n of irll of
thesc c()ltccrDs,

--...: j
 ^ Srsr.nrr¡i. Aptrc¡.h t() ItAaS r .iii (bcf.un c T..h ¡ (L,es 105

qt *ry

?
t06 Shon-Scd Facc-uft Techniqus

AesthatiaAnalysis
This S2-ycar-old woman requestcd pcriolbital, faci¡l, and neck rejuvenation.
Shewas conccrncd with her uppcr lid skin hooding, lower lid laxity and wrin
kles, cady lowling üth more ofa squarc facial appearance,and ncck larity.

NonsaargioalPhn
The teatment consistedof
o Skin careceatment with Retin-A bcgindng 45 daysprcoperatively

S*rghal Plan
Thc t¡eatmcntconsistcdof:
. A.ncxtcndcdMACS-lift
. An uppcrlid blcpharoplasty
. A lowcr lid blepharoplasty
¡ Submcntalüposculpturc
A SystcmaticApproach to MACS Lift Openúve Techniqúes
I0u \h!{r\.rr f¡¡r I rr L(.h¡ktr..

I'ostopewtir¿ Results
'l
hc prrrcedrrrh c se l c p l o r l L r e crdr l c r r r r i ¡ cr ¡ r c r , r lt li c i ¡ l f c j u \ c n r t i ( r n l. h c t r
ci.rltri.rnglcol i'outh h.rsbccn rcslorctlilnd rhc l)cfiorbit.rl,rfc¡ is si!lnrji.,rnth
| c j L r r c r r . r t cl rhl c. c r c 5 ¡ r e ( ) l ) c n b u f n ( )ht o l l o $ . , r n cr l n i c cf i r l l n c sLs( )t h c n r . r l . l r
r c e i o nh . r sb c c n. r r h i c r c r ll.l r c l r x r c rl i , l l r o l l r ¡ r n c siss i m l . r ¡ ¡ r r r lI.- i r \ i l \( ) l t l r c
j . r rlri n c . r n t ln c . l ( i s c ( r r r c t r ! (rl r i t h s i ¡ l r r r f i c r innt r ¡ r ' r r c n r c nol l r c c k s h . r ¡ r c . r r r r l
'l
c r ¡ n r r ¡ L r rh' .t c l l ¡ L t i r c n c \ rs¡ l ' t h cI l ; \ ( l S l i t i i s r l c n r o n s t r ' ¡ t chLt lt h c i n r l ¡ r r ¡c r l
n c c l <e ¡ n t < ¡ L r r r ( ls h i L p cj . r l r . r n r l n r i L l t i e cI.l r c l i r l c h c e hj L L r r e r i o i sne l c . r r l v
c l i r . r t c i rl r i t h . r\ h { ) f t c n i r r(q) tf h c l o r c r ' l i r ll c n q t h . l i c i l i t ¡ t c ill¡ v r n i ¡ . l l ¡ eeel e r . r
t i ,) r r. r r r (.lr p i r r . l rb l c p h . r r o ¡ l . r s r i .

Jishb-.

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 \ S \ \ f . ¡ r . r r i . 1 | | r { i . r . h 1 r ) , \ 1 1 (\ I i l l ( ¡ r . r r 1 r \ t l . . t r j r j r t L r \
109

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lI0 Short Sc¡r I¡ce Lili'ltchniques

Aesthetic Analysis
This45 yearold rvomanwm conccrncd with herstrongsomcrvhat angrylook
asrveilasthe boxyfcciallook with jorvlirg,earlymarioncttclincs,thc sador
downwa¡d curving of thc nouthJ arrd thc look of thc cyclids and glabellar
¡hyticls.

Nonsurgi,cal Plan
Thc treatmelt consistedof:
. Skin ca¡e treatment with Retin-A begirlning 40 dayspreoperatively

Surgicnl Plnn
Thc trcatncnt consistcdof:
. A MACS-lift
. An endoscopicbrow lift with sc¡ervfixation
. An uppcrlid skin-onlyrrinr
. A lowerlid pinchbleph;rroplasr

PostoperativeResults
AÍr cndoscopicbrow lift rvith scrcwlix.rtionclinin¿rtcdbrow ptosisirswcll irs
ghbellar Lines.Tlrc tcnporary cxtcrnal scrcwswcrc rcmovcd 14 claysaficr
surgcry.No 1¡t w:tsrer¡ovcclfio¡r thc uppcr licls,Thc lowcr licl ¡rinchblcph-
lroplasty nrdntainseyclic{position rvithout urdcsirrblc sclcr:rlsirorv.lrrvlinc
defilition and nasohbi¡l lblds rrc improvccl¡nd thc ovcr¡ll facialtlianglc of
,vouthis rcstorcd.

Improvementir the jawlile and r¡iclf:rceclevatio[ is t'u¡thcrcviclcnccof thc

ef-fectiveness
of tl.reMACS lift ír this ¡.raticnt.Thc midficc is sigrrilic¡rtly i¡r-
provedlvith the clranaticpositiveeffcctorr the rrasolabirllblds rcl ¡rrriorrcftc
lines.A very pleasantshapcand dcfinitior to thc j¡\,lirc is achicvcdrvith thcsc
tccluriques.Patients¡re often coocernedpreoperatively wjth a somewhats¡d
¡ppearaocethat is transformedlvith the MACS lift to one that is pleasingafld
happ)r
A s ) J e n J ü . q p p , { . \ r u \ 4 q ( s 1 , f t O p e r a u vTee c h n r q u e '
tt2 Shor¡ Sc¡f ltuc Lili Tech¡ilLrcs

Stu,gical Pearls
. The useofelectrocirrrtcryfi¡r ticc lifting is controversial.There hasbccn
concernabot¡t protccti()nof tlrc firci¡l nerve. 'fhe
disscctionplane fbr
the MACS lift is rclrtivcly supcrficiirl.I ¡rrfbrm thc liliing clirectl¡,sLr-
perñcialto the SMAS,thus conrpletcl],protcctingthe deeperJvingficial
ncrvcs.
Thorough infiltr¡ti<¡r rvith loc¡l ¡ncsthctic is a critical clcme¡rt in f¿cili-
tating electrocautcn,disscctiorr.Infiltratior offluid by l1o mcans inlritr,
its dissectiorr;in rcality, it eircrth, f¡cilit¡tc. it. Bv hvdrating rhc rissucs
the sofi tissucpl¡ncs trccorrc nrlgrificd rs do the distinct la,versbetu'ccrT
these anatoÍl'licDlirncs.
l'l'tc lcvel fbr ¡rro¡rcrclisscctionis clcarly visible thloughour thc rnljoritl
ofthis proceclurc,cxccptfbr thc smalltriirnglcofsoft tissuclrctwccnthc
infirior etlge of thc ofbiculrris ocr¡li ¡ncl thc supelior cclgcof thc plLr-
tysma. This is thc ouly iucx of clisscctionthrt is not cicfincctby ln irnir-
tomic ¡rlanclncl rcquircsjurlgmcnt rvith reglrcl to thc lcvcl of disscc-
tion. All ofthc d¡sscctioncxccpt fi)r this ¡rca is trulv ¿¡r¡tornicrvith rc-
spcctto tissucpl¡nc$.l)isscctio¡rofthis linal ¡rcx is grc.rtlyf¡c¡l¡t¡rcdby
visualizing ¡ planc bcnvccn the supcrior phrvsma ancl infcrior orbicu
l¡ris oculi ¡¡cl connccting thcsc structurcs.
'fhc
local ancsthcic flr¡id scrvcs¡norhcr rvondcrfirl pr.rrposcby instirnrlv
coolirlg thc clcctroc¡utcrv tip trd prcvc¡ting thcrmal injuq'.
¡ Ss'cllingaf'tcrtl'rcscproccdulcsis short livcd lncl gcncrrll,vlcsstharrthit
cluscd bv scissorrrlissccti(nr.
Most p¡ticntsrvl]o trndcrgothis tcchniqlrc
havcvirtuallyno bruising.Thcsclrc¡rclits ¡rc cntlrusiasricallycmbr¡ccd
LrvD¡ucnts.

Pirticnts.rtisfactidr
witlrthis¡'rt.occclurchirsbccounifirrmlycxcellent. Comt¡i¡,
ing l rvoldcrñll rcjLrvenation cflict tbr thc fircc¡ncl ¡rccklvith a vcry short rc-
covclv pcriod is iclealantl tlcsircclby ntost p¡ticnrs.BccirLrse ofrhcsc grc¡t ¡d-
vaút¡gcs,thc electricMACS-lifi h¡s bcconrcmv pret'trreclmethod fbr iirci¡l
rc)Llvcnirtlolr.

BIBI,IOGR.{IHY
l)inncr Mt, Gl¡ssm¡n H, Artz lS. Thc "n,) fl.rp" rcchniquc li'r loNcr-lid blcphrropl.rstr'.
A ( . r h c r i (P h \ r S I r g l o l 5 : . 1 5 8 , 1 9 9 1 .
lillcnbogcn \ Monkic (;D, l)iaz J¡vl.V)lunrcrric ficclifi Irbsrrrcr]. PlasrRcconsrrSurg
I l8:78,200ó.
H¡zr¡ti E. Mod'fiedshort flrp ficclili. Phsrl{cco|srrSurg l0l:l Ió5, f998.
Missih¡ H- Short'lc¡r f:rcclifi \\¡rh cri¡cndcdSñIAS pl.rnsma dissection.md I'tiing a'r(l
liDrircdskinundcmiring. PlllsrRcc(rrsúSurg I l2:óó3,óó9,2003.
McndclsonBC. Surge¡\'ofthc sLrpcrfici.rl nrrrsc
Lrlo¡polrclu
oric svsrem:Princ4tcsofre
lcalc,\'cctors¡¡d lira¡ion.l,lastRcconstfSLrrg109:824825,2002.
 A Sirstcñ¡¡ic (, MACS-l,iliOpcñriyeTcchónttrcs
Approach

ParkcsM, ¡ein W Br€rrnanH(i. linch tcchniquc lbr repiir ofcosr¡ctic evclid defbnni
tics. Arch Ophthalmol 89:324-328, 1973.
Rizk SS,Mat¡r¡sso A. t.owcr eyclid blephoroplasry:Analysisofnrdications ¡'rd rhe rrcxr
nrcnt of 100 paticnts.Ilast llcconstr Surg I I I rt299- 130ó, 2003.
RosenñcldLK. The p¡nch blcph¡roplaswrcvisired.Plasrll.cconstrSurg ll5:1405-14I2,
2005.
SrvlanZ. ¡rrsc string+-orrncdplicrtionofthe SMAS$,ithllx¡tion ro the zygomxticbonc.
I'l¡st ReconstrSurgI 10:667-671,2002.
Saylan Z. Thc S-lift:Lrssis morc.AesthcticSurgl \9,406,1999.
TonnrrclP,StúzinJM, N¡hri F. Inrcrxctivcviclco:ShorrscLlrf¡cclitt Iabstr¡ü]. Phsr Rc
constrSttrgI l8:52,200ó.
TorrrrirldP,Vcrp.rele
A, MonstrcyS, ct ¡1.Minimrl ircccss
crirrrial
suspensiou tift: A ¡todi-
6cdS 1ifi.PhstRcconstr SurgI0912074 208ó,2002.
 Refiningthe
MACS-Lift
Techniqueand
DefiningIts Limits
PatrickL. Tonnard . AlexisM. Verpacle
lló s h ( r t s r . , ¡F ¡ . { L . i l i l ¡ . h n i q u . s

\X/
Y V llcn rrc l¡egjrlrr.ing¡ rtgr'tcch¡icluc¿nclthc first rcsults:ucgcncrirlllpos-
iti|c, thc rcnr¡rtirtionis rcrt'¡crl to overusethc proccdurc,cnrploling trroad
indic¡tionsfirr thc technic¡uc. ll our carll cxpclicnccwith thc rVL{CSIift, n e
rvcre qr¡cl¡¡llv confi(rrted \\'ith sonc situiti()nsin $ lrich thc initiel lr¡sictcch-
rli(luc (li(t n()t irdcqu:rtclv
rlve thc ¡rirticrrt'sproblcnl.

In this cheptcr \\'c prcsent .r,r ()\'crtic\\' of thc ()bstaclcs\\'c cllcoulltcrcd itúd
thc nrcthoclsth¡t lllowerl Lls t() ovcrcone thc inrlcrf¡ctiolls of thc c¡r'h'
¡.lA(ls-lifi tcchoique.We fi¡cr.lson thc dcbiltc whcthcr t() opcrl thc lcck or
not,;rnclhorv uc cot¡l(lsobs¡ir¡ti.llh,ilrlcli()r¿tc ()rlrrcsultsin thc ncck usin¡¡.r
sccul'cplitfsna suspcrlsion. \Vc alsoprcscnt.rdctrilccj¡n¡lvsisof ¡ll lhc con'r
plicilti(nrscr¡countcrctli¡r our scricsrf ncirlh T00 cirscs.lvlirrorsr¡tt¡rcrcl.rtctl
ptot-rlcrttscrtcourrtcrcdand thc lclvlntlgcs lnd disirdlirntirgcs ()f c¡ch sr¡furc
tl ltc ¡rc addrcssc(i.

Wc ¡lv¡ rclicrl thc irnportlnccrf tlrc thir'dDr¡lirrsuturc,\'hich in our r4rinion

is ¡ r'irlLtirblc
¡ltcrrr¡tivcto ¡titny crrcnr.lcrl.rnd porcrrrilllt,d¡rrqcrousmicllicc
c(¡ t ccti()nscr¡rlcntl\'¡\'dililblc.

Mrrn¡,sttrgcotrs lrc rcluct¡nt t() uscthc prchxirlincincision,¡ncl lirr this rc¡son

rvc hir|c tlcrlic¡tctlil sc(ti()nt() ichicYi,rgl Problcnr-ficcsc.rrilr this rcgi()lt.

Wc prcscnt.ttlditionirlcrpclicocc rvith thc MA(lS'lifi es l sccontlrll litiing

proccclLtrc lirlkxling ¡ tfildiri()nllfitcclift. Wc cr:rnrincthc ditÍ¡rcr)ccsin p()st-
fircc-lilirrgingbctwcc¡ thc tfirditi()¡irlpr()cc(lr.rrcs.rnd thc vcrtic¡l MA(IS liti
rr'ifh rcsirrcl kr ¡r'oitli¡s un\\'¡otcri tircc lifi srignr.rte.

'l'hc
cheptclconclrrtlcswi[h ir sccti(¡r()¡rdiflict¡ltcirscsfirr stich thc ¡rossitrili'
tics lncl linritirtioos(¡frhc MACS lifi tcchnit¡Lre irc diseusscci.

WHETHER OR NOT TO OPEN THE NECK

Onc ofrhe first ir¡rpeals ofthc MACS-lifi tcchri(luc wils lltdr i¡ sccn¡ctlrrn¡cc
cssitlyto rlisscctth0 ncck rcgion t() obtirjn ¿ plc:rsingncck fciLrvcn¡ti()n. This
holds nr.rnv.rtlr',rnr.rges:lirst, it rctlrrccsopcritivc rimc, \'hich is ¡ rlclioitc ¡cl
vlntirgc in Procctlrrrcs pcrfi)nreclunclcfloc¡l ¡ncsthesiir. Sccon(1, ¿t lc¡st i[ cnr
of-incisi(nris cli¡rin¡tcrl sith;rll irs potcnti:rlmorbiditr'. I'hircl,the discornfirrt
:rnclcorl,¡lesccnccirssocidtcd $,ith i liposuctioncdncck erc signific.rndvlcss
th¡n \rith i¡ undcrrnincdncck fl.r¡r.Forrlth, iurd pcrhilpsnt()stintportitnt,the
r\{ACS'lift ¡lrids thc ¡rossiblcconrplicirtions ofopcnil!¡ thc neck.
 Rcnningthc ¡4-4.CS
LiliTc.hnique ¡nd Deñninghs Limr6 lt7

I{ematoma
Openingthc ncck aloneinc¡eases the risk of hematomathreefold.The¡e is a
higher risk ofartcrial bleeding,especially
when additionaldigrstric muscleor
submandibulargland resectionsare involved.In conjunctionlvith lvidc bilat
eraluldermining ofthe cheeks,sucha henorrhagccanprovokea major blood
loss.Compressionofthe trachcacancvenimpair intubationifthis provesnec-
essaryfor a ¡cvisio[ proccdure.

Seroma
Thc risk of seromaincrersesploportionally witl-rthc amount of dcad spirce
createdby urrclermining.L)rainagccannot:rlwayspreventit.

Skin Ischemia
The potential for skin ischcmiais directly relatedto increasedundermining
and thinning ofthe skinflap.This is evenmore likely to occurin vascularlyim-
p.tircdp.ttierrrs
lnd :mol<crs.

Skeletonization and íGunshot" Deformity

Skelctonizatio¡r and gunshotdcfbrmity (submentalcxcavation)catroccLll]cs-
pcciallyin conjunctionwith a subplatysmal fát rcsection.This probablyoccurs
as a result of a technicalcrror causcdby looscningof the plarysmrrrrhaph¡
overresectiolloi subplatysnralf'at,or thc cor¡bination of both. An undercor-
rectedneckcan alwaysbc rcviscdifthc patientdesires,and it nevcrlooks Lül-
natLrral.An overcorrcctcd,skelcto¡rized neck,on the other hand, looks abso-
lutcly uunatrualand is very hard ifnot impossibleto rcstorc.

Marginal Mandibular Branch Nerve Injuries

Marginal mandibularbranchinjurics can also occu¡ rf'ter liposuctionof the
neck, but this is very rarc ¿urd¡csultsfronr inadvertentsubplatysmal
suctior-
ing. After extensiveplatysmaplasty, with or without mandibulargland resec-
tions, this complicationoccurswith significantlymore frequenc¡ evenin the
most experie¡rced haflds.

The clinicalexperienceof7 yearsofMACS-lifting hastaught us tbat in 90%of

casesa more than satisS'ingneckcorrectioncan be obtainedby verticallysus-
pending the laterocranialedgeof the platysmain combinationwith liposuc-
tion, withoLrtany dissectionof thc ovcrlyingskin. This fact alonehassignifi
ll8 Shorr Sclr ljicc Lift Techdi¡tü€s

caDtlyreduccd opcrating time and coDplic¡tions :rnd madc the proccdure

achievablewith local anesthesia.
1'hisaddstremendouslyto thc appealofthe
-lift
I\4,{CS to the public.

Neverrhclcss, in reviervingour slidcswe fbund that in 10%ofour patientsthe

ncck¡vasinsulliciendycoücctcd. In halfofthese cases(5%),therervereresid-
ual verticalfblds i¡r the infralobularrcgion, *.hich were trc¡tcd by a postcrior
cervicoplasty; and/or hearryplatysmalbauds,rvhichneededdilcct cxcisionby
an antcriorapproach.The rclnaining5%were casesin which tltcrc wasa t¡ue
excessof sl<i¡¡i¡r the submentalarc¡Jwhich could only trc corrcctcdby com-
pletclyundcrnrining andredraping thc skin.

CaseBxample
Aesthetic Analysis
This 54-ycrr-oldrvomanrequcstcdminimallyinvasivefircialrcjuvcnation.Shc
had hcavythcialf'crturcsand thick scl¡orrhcicskin.Shch¡d ¡¡¡ obviousskin ex-
ccssin thc submcnt.üand u¡rpcr ncck fcgion) hcavyjowls, lucl cleepmari-
onettc groovcsrnci n¿sol:rbial fillds. Shcshorvcd¡ dcsccntofthc miclfhccwitl'l
x¡d corrcct pr>sitionof tl'rc
a¡ i¡rfi¡orbital hollow, rn rrppcrblcphirrochirllsis,
eycbrows.

Thc pr<xcdurcl,as cloneundcr kr¡l l¡tcstl'tcsia

s'ith intrrmr¡scul¡rmicl¡zol¡n'r
(3 mg) ¡¡rcltook 2 hours¡ncl l5 nri¡rutcs.
rclaxat¡o¡r Shc rvls dischargcd 2
hoursrftcr st¡rqcrv.

Sargicnl PInn
The trcatmcntconsistedof:
. Submcntalliposuction
. An extcndedMACSlift
. A lower pinch blepharoplasty
. Ar uppcr blepharoplasty
with f'atresectiolofthc two compart
ments

Pottoleretite Resala
The patient is sh<¡wnI year postopcrativcl),.In the fro¡tal vicw, thcrc is a¡
overallimprovcmcntofthe facialshapcfiom a rathersquarcto a¡rov¿lshape.
In the obliquc vicw,shcshou'sbetterdcfinitionofthe ma¡dibular bordcr,cor
rection of thc Drariolettea¡d nosol¡bialgrooveswith a better volume ill dlc
midface,corrcctior of rhe inl'r¡orbitalhollow, and blendingof thc lid-chcck
junction. -fhe cfltct ofthe upper blepharoplastyis obvious.
 Rfli¡i¡q rh. NfACSLifi Tcchr(uc rnd i)einnrs r¡sLimús rl9

wlrit is strildüliin rhc prolile vicr.is thc delinirc[ndercorrcctionofrhe ccrvi_

col¡cnt¡l il[glc Lrec¡uscofa t¡ue skin cxcess.This c¡n bc corrcctecl oniv l)v
i u r r r p l c t ru r d c r ' ) r r n i r rorf: r h c I l c i k . l j l l T l l i . $ . r sI , r o f u * , , ir o r l t . p " r i e r r rb, , r r
shc rcfiLsed;she *as happy \\'ith thc rcsults lntl unu,illing to Ll¡dcrgo turther
sLlrgcf\i

Perhirpsa slight overusc ofthe tcchni<1ucthrough our ct.rthrri.rsmhas xllo\\,cd

us to filter out the truc linritsofe tcchnit¡re* ithout undcrnriningthc necksldn.

Opciin!! evctv ¡rccl(nc¡ns ovcltre¡¡ntc¡ltir-tr¡irnt, citscs,Nevcr openüru ir

ncck is Ltndcrtre¡tl¡clltin i limitecldlltoLltrtofcxscs.()ur currcnt l¡rproirchis
still lo iur)id opcnilt!ithc ncck rvhcncvcrp()ssiblc.lhis conscrv:rtivc ¿ppro¡clt
is cctt¡inly rl s¡f¡ onc iltcl u,ill rlclivcr¡ sirtisli,irrg
rcslrltin :1ulrlxirllulunumbcr
()f:cilscs,
120 Shoft s.¡r Fi.. Lili T.chrntrcs

THE NEED FOR SECURE PLATYSMA SUSPENSION

A fcrvparicntsof the errlv seriesshorvan elrly rcla¡rseofs[bment¡l laxit\i In
thc first descriptionofthe MACS-lilt, the lo\\'erlimit clf the sl(in undermin
ing n'esrrbitrerilv determinedb,vthe nruclibular lrrgle. lhe rvo¡k of L)aniel
Llbbé (sce Chapter 7) hrs madc us rrndcrstiuldtl1¡t tllc l(cv to a st¡blc ccrvico
l¡clltil xnglc is l str(nr!!enclsccurcsuspcnsion ofthc liltcrocr:rnial
edgc ofthe
platysmamusclc.Dr. L¡l¡l¡é obtrins his cervic:rlsus¡rension by suturirrgthe
cliruiirlplatvsmalcd¡¡cto thc liganrcntof Loré, ¡ \¡ervstrong structLLre irt the
l¡ascofthc carlobc.Tlris is cx:rctlythc sanrc¡rrincipleofthe vcrtical<us¡ension
suturc ¡s in thc MA(IS-lili, bur rvith r difltrent:rnchor point.

'lb
cfflctivciv srrs¡rcrrrl
thc ¡rlatysm:r,dissccti(n at thc nr:rnditrul:rran¡¡1cshould
bc c¡r'ticclas f-ardc¡*rl ¡s ncccssrrvto ()btain r clcir vicrv of rhc pletysnr:rl
llbcrs.In s<¡nrcp¡tic¡ts thc plitv¡irnll cdgc is krrvcrth:rnthc nrantlibulerln¡¡lc
itncl¡ dissccti()nt() 2 cnr bclo$,thc nr:rnrlibular an¡llcrvill bc ncccssaryto cx-
poscthc platysm¡rnLlsclc. Thus in contrirstto \ ¡r:rt wirsclcscritrcd in thc e¡r'li-
cst ¡rublicltiors, thc lo$'cr lin'rit of thc skin clisscctionis not alwilys thc
m¡ndibr¡lir inglc, bL¡ttlrc lcvcl it wIlich thc cclgcofthc pl.rtysnr:r is sccn.

'l
hc first vcltic¡l sr¡spcnsi()n
kx4-rlcc¡rrircs
i n)inirlllulrof nr'o strong bitcs in
!hc pl¡rystllirmLrsclcbcfi)rcrcvcrsingthc clirccti<)11
of ¡hc sutllrc.

'l'ying
this sutrrrcrvill tr¡nsnit thc tcnsi()nt() thc subnlcntil iuc¡ irnclsllspcnd
thc ccrvic¡l lcgion. F'irilrrcto pr()viclcir sccurcgrip on rhc plit,vsnrdwill rcsult
in :rn clrlv rclcsc of tcnsiorr.This cxpllirrstllc rcllpsc i¡r se¡Lr¡lc¡rtirl
lirxit)'i¡r
sorncof oLrrc¡[l], ]rirticnts,
 R.lining rhc ñiACS Liti Tc.h¡ntuc:rd Dctini¡s Ir, Linjrr t2l

\-,

In this crlnio¡rostcr.ior.
viel of thc p¡ticnf,s lcli si(ic, i strong bitc is bcing
t¡kcn in thc crlniol¡tc¡.¡lpldrysrrlilcLlgc.

I
t
\j rrl\
¡

Pl¡t),sm¡lcicscentresul¡sfiour ¡ttcnr.¡atiotr ofthc lig¡ntcnt of¡urnas. Io !()Lltll

(/rli), thc platysnra
cclgeis high anclcl,,\e¡, rhc c.rlubr. In rh. cl.lcrll
tiül¡¡t,
thc plltvsnrahx dcscenclcd causinq¡n ittcnuati()nofthe cc.r,ic,r,r,e,rt,rl.lirg¡-.
'fo
repositiouthc pl¡t\.sm.rin irs vouthfill lociltion.I n,,¡...¡,,,:1"1
.,rr.i"rnil,
rrg rs rcqrrircdto grtsp the latcrocallLl¡lcrlgeofthc pl.rrlsm.r.
r22 Shor S.¡L ¡¡.c Lili T.dlriqucl

COMPLICATIONS
Thc incidcnccentl n¡tLLrcol-corrl)licrtiolrshs llr'gelvrenrcinedthc s¡l¡c o\,ct:
7lcus ofcxpcricncel'ith the N4ACSlift. Wc h¡ve ¡o*'tre¡tecl ovcr 600 pa
ticnts¡rd thc odds ofcncountering nervconlplicaticltls hive iltcrcascd.

Wc h:rc1 only ()rrcnrilj(n c()nrplicirli()n¡ scycrc4 liy 4 cnr lirll'rllickncsss[in

slrugh of thc chccl<in d pdticnl LrnLlcrgoing MAOS-lifi ¡s:r scconcl¡r't'fircc Iiti.
'lhc
p¡licnt wls l hc¡vv snr()l(cr\\,h{)rcfirscclro c¡Lritsnl()kingdcspirc(lrrf cx
plicit instfucti()ns.Formclll uc clicllro¡ consiclcrsnt()l(ingt<) Lrc¡n ¡trsolLltc
cr)ntr-¡indicirtion firr MA(lS-liftine in viov ol lhc lin)itcrl l¡dcrniining ¡n(l
shr¡rtchcckskin fl¡ps. lt hrrsbccorncincrcirsinglv clciu,horvcvcr', thlr srlol<inu
is irt lcilstdctÍinrcnt¡l!() w()undhcirlinuilnd cirninrpcrichcirlingin cilscs()f mirr
ginirl virscLrlifitvof thc sl<i¡.Orrrrcnrlr',rvc consiclcrsnlrkirg to bc rr rcl:rtivc
c(nrtrilinLlicati()n¡nd wc still strt¡rglJ'rdvisc!hc cii0cliclirtcs
firÍ MAOS lifti g to
stt4rsnrol<inu bcginning2 rrccksbcli¡c until 2 \\'ccks¡licf s!rr!!cr!.

In our prlcticc, thc t^,cr¡ll incidcnccof miuol complicirfions(u ithout pcrltir

ncnt (liLllregc)is currcn!ly 5%.Zcro pcrccnt$,orrld[rc iclcrrl,btrt sLrrgcrv\ ith
()ut ¡n\I corrplicirtiorrs
sinlplydocs not crist. Accorclingto l):rnicl llalicr, "Anv
co¡rplic¡tio¡r inciclenccovcr 5% shou[1 m¡kc onc rccoosidcrolrc's surglcll
techDiqLrc."

'1he
hen¡tone incirlclcc wcnt doln itonr 2% in our first scricsof250 p.r
ticnts (scc\¡olurneI, p. 273) ¡o the t)rescrlt0.9%(si\ c¡ses)in e popLrlationof
-1'he
637 pltients. morc than 2 ycrrs rgo.
llst hemrtoDlain this scricsoccLlrrccl
'l'his
clccre¡scdinciclcnccis thc rcsnltof7 \,e¡rsofsurgic.rlcxpcrierce.
 Reñninsrhc MAcS'Uft Tcch¡ique¡nd Defi¡in8 Its l.nbits 123

Table 4-l F.est¡ksNovcmber l999-Nover¡l¡er 200ó (N : 637)

Number Pcrccntage

Major (skinsloush) I o.2

Minor 5.0 \
H€¡¡.toná (nonclxsr24 n)onths) 6 0.9
-\curoprarG( <2 nonths) 3 0.5
Fro¡tal braDch(l)
Buccalbranch(l)
Mdrsin¡l mindibuhr l,ra¡rch(l)
Wourd problcn$(rcqui.itrgstrrgiralrevnkD) 7 I I
llolongcd swcllins(>4 wccks) 4 0.ó
l¡l¡cted sunrrcs(Mcrs¡leDc) 2 0.3
Palpablc knots
l'¡rfotid6stuh I 0.2

Neuropraxis(0.5%)
ln the first volumc, rvc dcscribeda cascofa frontal branchparalysis
causedby
cntrrporcntofthc ncrvein thc third suturc,which originallycrossedthc zygo-
matic arch (sccVolumc I, p.274). Sincethen u,c hlvc changedthe courscof
thc third purse-stringsuturc anclhrvc had no ¡rore fiont¡l brarrchproblems,
Ncvcrthclcss,wc cl'rcountcrcdtwo nlorc tcnrporaryncrvc parcscs,wlrich rc-
solvcdsDollt.ncouslvrvitl'¡in8 wecks.

One patientshoweda one-sidedrveakness ofthe upperlip, l,hich l,as o¡rlyvis-

ible on forccd smiling and pursingofthe lips. Speechand the restedñcial e"
pressionwcre not influenccd.The motion returnedin 8 u,ecksrvith no resid-
ual wealoress.This problemwasmost likely causcdby one bite ofthe second
purse-stringsutule bcing taken too deeply in the n'¡ostmedial part of its
coursewhcre thc nervc is more superlicial,causi¡gan entrapmcntof onc of
thc buccalbranches.
t2+ Shorr-Sc¡rF¡ce-LilrTechrnrues

A thi¡d nerve lesion consistedofa n-rarginalmandibular branch paresis,which

also rcsolvcd aÍtcr lessthar 2 months. It is r.cry unlikel,vthat it was causcd b,v
a pursc str_i[gsuturc entrapment, becauscthc position of this nervc is not rn
thc coursc ofthe MACS-lift sutures.This complication was likcly tirc rcsult of
misdircction of the liposuction cannula under thc platysma.Wc havc also en
counteredthis problemwith isolatedsutrmentalliposuctions.

Wound Problems Requiring Surgical Revision (l.I%)

The skinitrcisiotrat thc temporalhairlineis not consideredan option by minv
surgcons.Vertical¡cdfapirg of the ski¡ in a MACS{ift requircsusing a prc-
hairline i¡cision to avoid unacceptableraisingof the temporal hairlinc and
leavinga typical face-liftstigma.If executedproperly accordingto olrr (see
VolumeI, p. 48) and others' recommcndatiorls (Connell and Camirand),thc
quclity of thc scaris not disappointing.This tcchniqueand the resultsare il-
lustrctedthroughout this volume-all postoperativepictulcswere takeowith
thc hair combcd bchi¡d thc car so that the scarcould bc wcll obscrved.In
only scvcllciscsin our scricsdid thc scarhavca tcndcncyto sprcrd.Tl'riswas
typicallyseenin ¡l:rtientswith thick, oil¡ setraceor.rs
skin,:rnd mostly on botlr
sides,Sr,rrgicalrcvisionunder local anesthesia 6 r'nonthsaficr surgerysolved
the problen1. Now we canwárnpatients with thistypeofskinbefbrehand, and
ofllr thcrr a sim¡llesolutionifnccessary,

Prolonged Swelling-Longer Than 4 Weeks(0,6%)

Onc rcaso¡ for thc ¡'ropularityof thc MACS-lift techniqucis thc quickcr re-
coverythat fbllows a lcssinvasivedissection.Wc tcll our patientsthat 2 to 3
weeksofsocial inactivityis normalaf'teran extendcdMACS-Iift. However,for
rcasonsuulorownto us,a few paticntsdcvclopcda stubborr and plolongcd fi-
cialedema,in onecaselastingup to l7 weeks.

This patient is shown 8 weeks,12 weeks,and ó months postoperatively.She

reportedcompleterecoveryofthe swellingafter l6 rveeks.In thesepatientsall
obvious causessLlchasvigorousfacialmrssaging,healy exercise,and endo-
crile pathologywcrc cxcludcd.Fo¡tulatcl¡ thc frnaloutcomcwasgood in all
ofthesecases.
n w e e k sp . s t . D e r a t v e y l2 r¡-15 po. urr ¿ \. / ti mo¡llrs póslopcratve y
126 Shon s.¡. F¡.r Lih l..hnqL,.!

Infected Sutures (0.3%)

A qranulomatous intlction ilonr¡ thc c(n¡rsc of thc purse-string sutr¡rc \\as
scc¡rin trr o c¿sesin rrlticlr l\'lcrsilcnc l irs usetl. Thc iufictiou resoh-eclafte¡ rc
¡ror'¿rlof-the lholc strturc,r'ithout irll¡cting thc c(xlcction. For tbis rcasor'r,
Ne stoppeclusi¡g this srrturcmirtci¡l (sccp. 129).

PalpableIGots ( 1.470)

l)ilp.llrlcknots()ccur¡crliuiti¡llv rvith ltrolcrrcsL¡Lrrcs, cspcci¡lhin thi¡r skirr¡rcrl

prticnts. I¡ s(r'Dccilscsthcsc \\'crc cvcn ¡r.rinlirlNhcn thc rxcrlvinq skin \\'¡s
'l'hc
¡ouchcdor rrtcn slccpinron th:rrsit1c. sLrtrrrc
lr¡d ¡r bc ¡c¡ro.r'cdto so[c
this pf()blcm. ¡-o rlctcliorntit¡rol thc liliirrg cfii'Ctin rhc firccrr'¡sn()rcd. l lris
problcnrstill <rcurs occlsion.rlh,[rut lrcc¡uscl c ¡rc using rcst¡rlr¡blcPl)S sr¡
()uf p¡ticrts tlrrt this \\ ill dis:r¡rpc.rr
turcs,\\.cc:l|rrcirssL¡fc sporrtucorrslvirf-tcr
¡ fct nrorrlhs.

Parotid Fistula (0.2%)

This r'¡r'c bu¡ fcnr¡fkirble conplication oc-

cufrc(l in i ó3 1,cirr-olrl rvom¡n uho h¡cl h¡cl
¡ t¡cc lifi ó yc¡rs Lrcfile.Shc presentecl u'ith
rccutrcrlt rrccklirxitr, jol,ling, n¡sohbi¡l irncl
n l r r ' i , ¡ ¡ r c l t{ er , ¡ ) \ e s . l . r t c r . rl rl r r ¡ r rf t o s i s . u l
¡cr li¡r ptosis,.rncl ¡triru¡l rhvtids.
 Refinnrgthe MACS-LifrTcchni¡lue¡nd Deñninglts I-ihrs 127

Sherurde¡w-ent an cxtendedMACS-liii with submcntil liposuction,a tempo-

ral brow lift, a pinch lower blepharoplastv.
a lip lift, and a perioralerbium:YAG
laserresurfacingunder a local ancsthesi¡with int¡¡¡nuscularmidazolamscda-
tion. The ñrst postoperativeday thc dressing$.asremovcd,ard no problcrn
rvasencountcrcd,

6 daysposloperalively l2 daysposloperaiivsly

On postoperativcday ó, at the tin'lc ofsuture rcnoval, shc prcserrtcdwith a

fluctuantswellingof thc right chcck,whichwasclinicallydiagloscdasa latc
hcm¡toma.Nccdlcítspi¡ation produccd20 ml of scrosanguincous fluid. llc-
causcofa slight infllnrmltory aspcctofthc skir flap,shcw¡s startcdo¡r an oral
¡m<¡xicillin-clavul¡r'ric
acid rcgimen of 500 mg o,ery ó hours.The ncxt day
shc prcsentcdu,ith a rccurrcntswellineiand l5 ml wasaspirlted.

On postoperativcdry I2, the swcllingrccurrcd.This tinlc 3Onl of cl¿arfluid

wasaspiratediftcr thc patielt rcpoltcd r suddcnorrsctofthc swcllingduring
a mcal. Suspectingr parotid leak,wc rcquestcdthrt thc xmylxsclcvcl in thc
fluid be measurcd.Twenty-four hours latc¡ the analysisindccd revealedan
amylasclcvel of 445,000 IU,/L-thc h¡llmark of a parotid leak.The paticnt
wascalledback to thc office for trcatnrcntrvith botulinurn toxin, rvhiclracts
on acetylcholincrcccptorsofthc cxocrineaciniofthc salivaryglandsto bloct
thc sccretion.Forry-rwo millilitcrs of parotid fluid *,as aspirated.A grid wrs
drawnoverthe parotidregion,dividingit into squarcsof I cmr.Evcryinterscc-
tion wasinicctcdw¡th the cquivalentof0.5 units of Botox.Thc ¡rextday45 ntl
of fluid wasaspiratcd.On postoperativc day 16 (3 daysrficr botulinum toxin
injcction)the volumc ofaspiratehad diminishcdto 20 ml.
128 Shorr ScarFace-Lili Techniques

I daysaltsrtr€aimeni
wiihbolulinum
loxin

Nine daysafter the botulinum toxin wasinjected,there wasno more fluid to

aspirate.The rest of the postoperativecoursewasuneve[tfu], and a satisfoing
resultwasobtained.

The 8-month postoperative resultis shown,demonstratinga good correctiolr

ofthe neckdown to the cricoidcartilage,correctionofthe jowls,a replenished
midface,a shortenedupper lip with exposureof thc upper vermilion,and ef-
facementof the perioralwrinkles.

In meetingsthe question is often askedwhether dre MACS-lift presentsa

higher risk for parotid gland leak.The incidenceofless than 0.2%showsthat
the risk is not higher than with a classicalSMAS flap dissectionin which the
parotid glandcanbe injured aswell. This rarecomplicatiorlis unlikelywithout
preexistingfactors,becausemost ablativeparotid surgeryheálswithout any
leakor fistulaformation.In this case,the patientreporteda habitual"tension"
in the parotid regionbefo¡eandwhile eatingcitrusfruits, raisingthe suspicion
of a preexistingstetosisof Ste[o['s duct. Sialographyperformed2 months
afterthis eventcould not, however,confirm this hypothesis.
 Refinins the MACS'Lift Technique úd Defi¡ins lts Limrs r29

THE CHOICE OF SUTURES

A common misconception is to think that suturesalone can permanently cor-
rect soft tissueptosis. Suturesplacedunder tension in living tissuealwayscause
a degreeofp¡essurcnec¡osisat the endsofthe loop, and thereforeeventually
slip through the tissues.For t¡is reason,any technique ¡elying purely on deep
tissue sutures,whether barbed or not, placed by puncture without dissecting
or moving anytissueplanesis doomedto be temporaryat best.

Many subcutaneoussculpturingtechniquesare used including imbrication,

plication,rrhaphy,andpurse-stringsutures.The efhciencyofthese techniques
is att¡ibutableto the following principle:when subcutaleoustissuesare re-
arranged,theyhealtogetherwith a degreeoffibrosis.Skir redrapingandresec-
tion ca¡riedout in the samedirectionasthe deeptissuelifting (that is, vertica,
stabilizeüe sculpturedsubcutaneous tissuesand a longlasting correctioncan
be expected.If the vector of skin redrapingis perpendicularto (that is, hori
zontal) the subcutancous sculpturing,the lifting will not be supported.By the
time the subcutaneoussutu¡es lose thcir strength, the ovcrlying skin will
stretch vertically downward. This explainswhy many suturing tcchniques had
a bad reputation-üe skin redrapingand resectionwerc not vertica.l,but rather
obliqueor hodzontal.

Either permanentor resorbablesuture can be used.The cor¡ectionis stabi-

lized by tissue healing and not by suture strength. This was clinically evidcnt
aswe switchedftom permanentto resorbablesutures.Inidally, only Prolene
and Mersilenesutu¡eswere used.Prolenehad the disadvantage of being very
stiff, sometimesleadingto palpableand evenpainful knots at one of the an-
cho¡ points.

Mersilenewasusedto solvethis problem, but

after two casesof granuloma formation on the
suture a few months after surgery, we abán-
doned this suture aswell. One patient is shown
at l¿lt Note the inflammatory aspect of the
overlying skin with a tendency to abscessfor-
mation, necessitatingremoval of the Mersilene
sultüe,
130 Short-ScdFace-LiltTcch¡ioucs

Removing bothersomesuturesafte¡ a few months apparentlydid not influence

the facialco¡rection.This madeus think diffe¡endvabout üe role of the su
tu¡es, and we started using slowly resorbablePDS sutures.After using this su
ture for 3 years,we are confident about the stability of the ¡esult, and ifa pal-
pable knot appearsin a patienq we ca¡ reassrueher or him that this problem
will ¡esolvespontaneouslywithin 3 months.

A sca¡reachesits maximum strength after 8 weeks.PDS ¡etains its st¡ength for

approximately 3 months. This createssufficient time for the prehairline sca¡to
healwithout tensionso that a tiin scarofgood quality canform.

SIMPLB AND SAIE MIDFACB LIFT

The midfaceis a difñcult regionto treat,mainly because ofthe risk ofcausing
lower eyelid distortion. Nevertheless, including it in any facialrejuvenation
plan is essential
to obtain a harmonious¡esult.During üe last decades,sever-
al techniqueshave been describedto produce a rejuvenatingeffect on the
midface.Most of them usedeepplaneor supraperiosteal or subperiosteal dis-
sectionto mobilize the soft tissuesof the face.dthough remarkableresults
havebeendescribed,thesetechniquesarenot free ftom seriouscomplications
such asfacialne¡vedamageand ectropion,and often show significantdown-
time becauseof prolonged edema.By using suspensionsuturesin the very
superficiallevel,a better canúleveris availableto redist¡ibutefacialsoft tissue
volumes.The malarfat pad and the temporalismusclefasciaare sturdy struc-
turesto reliablyanchorsuturesto. Using the malarfat pad asa vehiclefor lift-
ing, midfacecorrectionwith purse-stringsuturesappearsto bc effcctive.

We were extremelyenthr¡siastic about t}te use ofvertical suspensionof facial

soft tissuesofthe lower third ofthe face;thereforeit wasa logicalstepto use
the samesurgicalprinciplein tlle midface,It flt perfectlyin our hypothesisthat
the only rejuvenating vector in tl¡e face is the ve¡tical one, a¡d t¡at any horF
zontal vector on deep tissuesor skin merelyproducesflatteningof the face
witl¡out cont¡ibuting to its rejuve¡ation. Vertical Jifting of üe region of tie
malarfat pad canbe simulatedin f¡ont ofthe mirror and softensthe nasolabr
al firld, replenishesthe infraorbital region with disappearanceofa ma¡kedlower
eyelid-cheekjunction, ard reducestlle vertical height of üe lower eyelid. As
the a-nchorpoint for the third purse-string suture, we chosea location asver-
 Refi¡ing rhe ¡4-{CS-LiftTechniquea¡d Deñningtts Liñtr\ l3r

tical aspossibleabovet¡e malarfat pad. The decp temporalfasciajust lateral

to the late¡alorbital rim, in front ofthe f¡ontal branchof the facialnerveap-
pcarsto bc a solidandsafeanchorpoint for this purpose(seeVolumeI, p. 4l ).

The sutureis usuallvtied under maximaltensionbecause overcorrectionis iÍr-

possible:the malarmound cannotbe movedinto a nonanatomicposition ifit
is not releasedfrom its underlyingattachmerts.This is in cont¡astto subpcrr
ostealor supraperiosteal midfacelifting techniques,which allow completere-
locationof facialvolumcs.

Thc dccisionto perform a simpleor extendedMACS-lift and to use two or

threeplrrse-stringsutureshasto be basedon the needfor midfacialrejuvena-
tion.

Initiall¡ we thought that thc third suturcwasindicatedmorc in older paticlts,

but we gradually¡ealizedthc bcneñt cvcn in youlgcr paticnts. Thcreforc
whethe¡to add a thi¡d suturehasto be evaluatedin eachcase.However,it is
important to appreciate that this third suturewill alwaysproduceskinexcess ir
the lower eyelidthat requiresa simpleskürexcisiorvia a lower blepharoplasty
incision.Often 5 mm, and somctimcsup to I0 mm, of skin cau safelybe rc-
movcd, cspeciallyin thc paracanthalrcgion, without any risk of cctropion or
sclcralshow,becauscofthc strongsupportofthc lowcr eyclidby thc suspcud-
cd malarfat pad. This malarsuspension will alsopush thc bulging fat of the
medianand lateralcompartmentofthe baggylower cyclidbackinto the orbit,
rcducilg thc uccd for anyadditionalfat rcscctio[ in tl]cscconpartrncuts.

Talkir,g to collcagucswho arc usiug the MACSlift tcchniquc,wc ¡oticed a

certai[ rcluctanccto usethe malarsuspensio¡sutureand perform a¡l exte¡d-
ed MACSlif't. It is possiblethat this sutureis technicallyslightlymore diflcult
to place,but it is defifitcly worth the cffort (secVolumc I, pp. I22-I27). It is
our strolg convictionthat usilg this third suturcis onc of thc most powcrñll
fiatu¡es of MACS-liftirg bccauscit providcsa vcry simplc¡nd safl rncansof
midface¡ejuvelatior. Thc ccntralfacialtrianglc,with thc midfaccand cyclids,
is thc truc eyc-catcher, a¡d its correctionis essential
to achievea rejuvenating
effect.This might evenbe more important than creatinga perfect90 clegree
cervicomefltala[slc.
t32 Shori-ScarFace-LiftTcchniques

Case Examples
AestheticAnalysis
This S5-ycar-old woman prcsented for facial rejuvenation. She showed mild
ncck skin laxity with moderatcjowling and marionefte grooves,moderatenaso-
labial folds, and nice facialarchitectr¡rewith promincnt zygomatic bones.Most
strikingwasthe looseskinin her lower eyelids,üth largeverticaleyelidheight
and a marked nasojugalgroove extcnding into a marked eyeüd-cheekjunction
laterally. Her upper eyelid was hollow on thc right side, and her eyebrow was
low but had a horizontal,straightshapc.

This procedurewas done unde¡ local anesthesiawith intramuscularmidazo-

lam rclaxation(3 mg) and took 2 hoursand l0 minutcs.The patientwasdis-
charged2 hoursaftersurgcry,

Surgical Plan
Thc trcatmcntconsistcdof:
. Submcntalliposuctionandsuctionof thc jowls
¡ An cxtcndcdMACSlift
. A lowcr pinch blepharoplasty

PostoparñtiyeResalrs
Thc paticntis shownI yearpostoperativcly. The ncckskinis tightencdand ttre
modcratciowling is corrected.Notc the cffect on thc nasolabialfold. Most
sriking is the eflect ofthe third suturcon the midface,The malarvolume has
beenüfted upwardtherebyreducingthc verticalheight ofthe lower cyelidand
causingtie eyelid-chcekjunction to fadc. The transitionof eyelidsKn into
chcekskinis now smootherand looksmo¡e vouthful.Thc orbital reeionlooks
lessskclctonizcd.
l l . l i ¡ i n ! r h . ¡ 1 , \ ( . \ l . r l t l . . i r r . ! ! c . r r \ l L ) . r i L , r gl i \ I i f r n \ 133
134 Shor¡ Scarrace LiftTechniques

Ae*hetic Analysis
This 48 yearold man requestedcorrectionof facialrh¡ids and earlylaxiry In
the frontal view, dre most striking featurewas the empty midfacewith very
dcepnasolabial foldsprogressinginto the madonettegrooves.The inftao¡bital
region washollow with ¡edundantskin.The hear,yeycbrowsshoweda ptotic
tail. In the obliqueview,the cmpty midfaceproduceda skeletonizedeffecton
the orbital region.Skin laxitywaspresentin the lower eyelids.

This procedu¡cwasdone under local anesthesia with iutramuscula¡midazo-

lam rcl¿xation(3 mg) and took 2 hoursand 30 minutes.The patientwasdrs-
charged2 hoursafter surgery.

Nonsut'gicnl Plan
The treatmentconsistedof:
. Botulinum toxi[ in the frontalismuscleto correctthe horizontal
foreheadwrinldes

Sargical Plan
The treatmentconsistedof:
. Submentalliposuctionand suctionofthe jowls
¡ An extendedMACSlift
. A lower pirch blepllaroplasry
. Lateraleyebrowptosiscorrectionby direct excisionat the supe-
rior marginofthe tail ofthc eyebrow

Postole ra,tie e Re sa ltt

The paticrt is shown 2 yearspostoperatively. He showsa striking replenish-
nent of thc midf¡cc lvith correctionof the nasolabialfold afld na¡ionettc
groovcs.The infi":rorbitalhollowing is correctedand the lower eyclid skin is
tighter. I[ the oblique view, note thc improved volume distribution in the
midface, tnlsforming thc skeletonizedmal¿r area inro a more youthful,
healthicrshapc.Mid{ircereplenishmentis the result of the actioflof the third
sutureand the lowcr cyelidpinch blepharoplasty. The tail ofthe eyebro$,hasa
highcr position after the direct excisioo,leavingan inconspicuousscarat tlle
uppcr limit ofthe eyebrowhair implantation.The centralpart ofthc eycbrow
look mo¡e relaxedaftert¡catmentwith botulinum toxin.
SCI !roLrt \¡r iurL .r(! fuf ¡ i ,ruL|¡t. LI i s )\ l\ rL!;tLLL!rrrlr
13ó Sbo.t sc¡r tace Lift TechDiqucs

Aestbetic Analysis
This ó2 ycar old woman requestedperiocularrejuvenationand minimally in
vasivcfacialcnhanccmenr.Shcshowedminimal necklaxiq,,moderatejorvling,
mariolctte groovesand nasolabialfblds, good architectureofher zygomatic
area*'ith incipientdemarcationofthc cyelid-chcckjunction, slight fat hcnia
tion of the lower cyclids,and minimal blepharochalasis
of the upper eyelids.
The eycbrowpositicnwascorrect.

This procedurewas donc under local ancsthesia with intramuscularnidazo-

'l'he patient
lam rclax¿tioll(3 mg) lnd took 2 hoursand 40 minutes. wasdis-
chirrged2 hoursaftersurgcry.

Nonsurgicnl Plan
The trcatmcntconsistcdof:
. A Retin-Askin carcprogram

S*rgical Plnn
Thc treatmentconsistedof:
. Submentálliposuction
. An extcndedMACS-lift
. Transconjunctival
fat removaland pinch removalofthe lowcr
eyelidskin
. An upper blepharoplastywith minimal fat removal
. Erbium:YAGlaserresurfacingof the lower cyelids

Postobera,tiv e RestalB
The I'year postopcmtivcphotos show bcttcr definitio¡r of the mandibuiar
border aftcr corrcctionof jowling and ncck Iaxitl,,with a sharpenedcervico-
neltal alglc rlaintailcd durirrg downwardgazc,In tlrc oblique vieq the ef
fect on the midfirceis seenin the dininishcd nasolabialfbld; bcttcr projcction
of the malaren-inence;and an improvccltraDsirionof cyclid skin i¡rto cheek
junction and nasojugalgroove.The
skin, ir.rdicatcdbv thc fldcd cyclid-cl'rcck
uppere,velids look morc youthful aficr tl'rcLrppcrlid blcpluro¡rlasryNote the
excellentquality ofthc prc:ruricularancltcmporalprch:rirlinescars,permitting
a oonvtail-fiicndlvhairswlc.
138 Shon-Scar Face-lift Techniqucs

AesthetiaAno$ris
This 5ó-ycar-old woman prcscnted for rejuvenation ofthe lower and middle
third ofüe face. She had platysmal bands in a lax submental and upper neck
region, jowls, ma¡ionette grooves, downward slanting of thc co¡ners of the
mouth, uppe¡ lip rhÉds, markednasolabialfolds, and cmptincssofthc mid-
face with hollow lower eyelids.She also had hollow, empty upper eyelids and
correct cycbrow positioning, Note thc inframa.la¡hollow in the oblique view.

This procedurewas doqe under local anesthesiawith intramuscularmidazo-

lam relaxation(2.5 mg) and took 2 hours and 10 minutes.The patient was
discharged2 hours after surgery.

S*rghal Plan
Thc trcatmcntconsistedof
. An extendcdMACS-lift
. UPPcrüPcrbium:YAGrcsurfacing
. A lon'cr pinch blepharoptasty

PosnperatioeRes*lt
The l-year postopcrativeresultsshow correctionofthe ncck and submental
laxity (including thc plastysmalbands)with rcstorationof the ccrvicomcntal
angle; rcdefinition of üe mandibular border; corrcction of thc jowls, mario-
nette grooves, downward slant of thc corncrs of thc mouth, and pcrioral rhy-
tids; diminishednasolabialfolds; and a replenishedmidfaceand lower eyelids
with augmentation of thc rygomatic area,producing a youthfill cu¡vature on
the obliquc view.

The downward-gazingüew (the so-calledB¡uce Conncll view) not only

shows thc correction and stability ofthc cervicomcntal anglc, but also the re-
juvenatingcffecton the lower and middle thi¡d ofthe facc.
 , t.ty

\
\ \

\u
\:.\

b
<
 I+o \n,rr \.rr li.r.. Ll¡ l(¡rrilt e\

l hc tlc¡¡ilcr.lviel s r¡l thc rrrirlillc¡hilrl ol th¡: l.recrlcnronstr-.rtc blcntlingot rhc

l i t l c h c c l <j u n e t i o n ¡rr(l r e(lr¡(cd\ effi..rl hciqhl ()f ¡ h c l o r rc l c v c l i t l .

l h c r l c t . r i l c rt li c r r so f r h c k l l ' c l r h i r i l o l r l r c l i c c h i g h l i g l r ¡r c l i o r . r lr c j L r l c l . r
fi()n rln(l f()l.rltlisir¡pcrr-lncc ofthc plirttsntrlLrirlltls.

-r
 Reñni¡grhc ¡'IACS-Uñ Tcchniqueand Delini¡g Its ümrrs r4l

THE NEEDLESS FEAR OF THE TEMPORAL

IIAIRLINE INCISION
The prehairlineincisionhasa bad reputationamong many plasticsurgcons.
Our expcricncedoesnot supportthis concern.Ifone adhercsto the followilr"
basicprinciples,therc is no rcasonto fearthis incision.
. Make a zigzagincisionand rcsectthe skin in a linear ñshion (seeVol-
une I, pp. 48-49). This will help in dealingwith little skinfblcls,because
it compcnsatcs for the incongruencein length betweenthe incisionside
and the flapsideand will avoida straight-linescar,which is more visibte
at thc hairline.
. Bevelthe incisionand excisionof skin.Hair üll grow through thc scar,
therebyhiding the ñnal sca¡a fbw millimeterswithin the sideburn.
. Ensurea tcnsion-freeclosureby avoidingexcessive skin excision¡fter
verticalskin redraping.
. Do not extendthe incisionhigher than is absolutclynccessary. In rhc
majorityofcascsthe incisionendsat thc lcvcl ofthe tail ofthc eyebrow
Morc craniallythc skin bccomcsthinne¡ and the hair implantationlcss
dense,which increases the risk ofscar visibility.

Occasionall¡4 to ó wceksafter surgcr¡ smallinclusioncystsmay appc¡r on

thc tenporal hairlinc part of the scar,indicating lrreakthroughof the hairs.
Opering thcsccystswill lrec this ingrowing hiir. To emphasizcthat thc fc¡r of
making thcseincisionsis unwarraotcd,nost of thc cliuicalcasestltrougho!¡t
this volune wcre photographcdwith hair combedbehinclthc car.

THE MACS-LIFT AS A SECONDARYFACB-LIFT

PROCEDURB
One of thc biggestadvantagcs of thc MACS-lift is that it gcnerallyprovides
natural-appearing results.Thc ve¡ticalrepositioningoffacial volumesand ski¡r
is strictly an rntigravitationalmancuvcrThis meansthat aftcr the MACS-Iift,
thc facewill contiÍlr¡eto look natunl evenaftcr flcial soft tissuesbcgin to de-
sccndasthe rcsultofnormd agiugprocesses.

In more than 7 yearsofexperiencewe still haverot seeÍrtl'rel¿teralrpecpphe-

,tornenonit\ any of our paticntspostoperatively. We attribute dris rcsult to
moving both thc dceptissucs.ud skinin pa¡allclin the samevertic:rldi¡cctio¡.
Wc rcconsideredthe caüsesofthe lateralsweepphenomenotr¡urclconcludcd
th.1tit is most likcly causcdby decoDrpositionofthe l¿tcralvcctorofskin cor-
rcctiol nnd the verticalvecto¡ of skin aging. This vector is complctelyinde-
pendentof the cleeptissuecorrectiori,which is verticalor oblique-vcrticali¡
t42 Short-Sd Fáce-Lift Tcchn¡ques

most techniques.Redraping the skin horizontally will invariably lead to a flar-

tcned,windsweptappearance, ifnot after the fint, then certainlyafter several
facelifts.

In a t¡aditionalSMAS faccJift procedurc,the SMAS is typicallysuspendcdn

a mainly vertical dtrcction (red anon). The skin, however, is redrapcd morc
horizontally Qellow anow\ creating a tcnsion on üc skin in this direction
(yellowdadtedline).^lhe vcrticalcomponentofthe skincorrectionis minimal.
Gruvir'¡ (bluearrow) continues to pull downward on the skin flap. Becauscthc
tersion on the skin flap is mainly horizontal,it hasno defenseagainstdown-
ward pull and this will result in a curtainlike deformity (yellowcurved lincs)
known asthc lateralsweepphcnomenon.

When creating the skin flap in a sccondaryface-lift case,wc find it remarkable

how much the skin sometirnesrctracts antcriorl¡ demonstrating a relative
shortageof skin in the ariteroposterior directionafter prior latelaltraction on
the skin flap. This signifiesthat there is certairilyrio rclaxationof horizontal
tcnsion on the skin-on thc cont¡a¡y! Thus recurrent skin laxity after prior
facelifting is only in thc c¡aniocaudal
direction,c¡earingthe downwa¡dcurvcd
ficlds ofthe lateral swecpphenomcnon. Therefore even more t¡a¡l in primary
facelifting, horizontal traction on the skin is not effectiveand is absolutcly
contraindicated whcn aimingfor a naturalfacialrejuvenation.
 Reñ¡nrgthr MACS-Lifi Trchnique¡n.l DefinnrgIts Linnrs 143

Natural Aging
Currendy none ofour triL{CSJift patients havc requestedreo¡reration.Never
thcless,\4'elolow that aging is natural. The following cascis presentcdto dem
onstr:lte long,term ¡esults after MACS-liftillg.

Aesthetic Ana.ltrtis

This 63-ycrrr-olcllvor¡l¡ rv¡sclcscriL¡cd

in Volumcl, ¡r. I90. Slrcprcscntcdwith
gcncralsaggingofthc midfirce,obvi<¡l¡snasol¡bitl fblc{s,nurioncttc groovcs,
jowling,andan obtuscccrvicontent¡l inglc rvithobviousphtysmalbrnds.She
w¡s onc of thc first pxtic¡¡tson who¡¡ we performed¿n cxtc¡rdedMACS-lift.
Shc ¿lsohad i'ln uppcr blepharoplasty ancla transconiunctival lowcr blepha-
roplasty.In the first yc¿r th¡t wc pcrfbrmcd exte¡dcd MACS-lifts,orLrthird
slrturcw.rsdircctcclmorc obliquelywith its aflchorpoint on tl]e deeptcmpo,
ral fásci¡ next to the first ¡nd secondlnchor point in f¡ont of thc cr¡. This
shiftcd the nal:rr flt pad too mLrchl¡tc¡¡rlly(sccVolume I, p. 48). No lor,,,cr
pirch blephirroplasty waspcrfbrmcd irt ¡hcr timc, beccuscu,c dicl not lifi thc
mllar firt prd verticallycnongh.
14+ 5hr!t S.rr I r.. l. r1 lc.l!riqucs

PostopcrativeResubs

'lhc
p.rtienris shorrrr6 r'clls postopcrrrtircll',.rt .l:c a)9.()n ti(rnr¡l \ic\\'. rlrc
s h . r ¡ co f h c l t r r c cs r i l ll o o k sn r ( n c\ ' ( r L t r l t l tLht .l l t rb c l i ) r et l t c s u t q c r \ ' ¿\ ), c t r sc . r r
licr.lhc n¡.rncljhLrl.r'h¡-h r lrcrlsr c t ¡ i l t c c.lr b c t t c rL l ¡ ¡ h n i t i o n . r nr ldt c j o r r l si r l t l
nrilri()ncllcqr(x)\'cs.lrc still corrcctcrl. lhc nrrsol¡Lri¡llirlds lt.t!c |cl.tPscci
sliqhllr rn(l thc cfli.l in tlre nrirlt¡ccis tlinrinishccl.l lris is plrrb.rblrLrcc.rrrse
_l
rr e rrserlr lcsscllictir r oblir¡trer cetor-ot rr-¡crioltil rhe,icell lv c¡scs. hc cllicr
( n r l h c c c r v i ( ( ) n r c n t.¡ul r g l ci s s t i l l\ i s i L ) l rct t c f 6 r c r r s .
 RcfininsrhcMAcS-Lift Tcchniq(cánd Defning
I$ L,ñ,rs 145

The most important lessonwe lea¡nedftom this patient

is rhat aging appears
to happennaturallyaftcr a MACSJift proced¡.¡re.
Shedocsnot toJt inn".ru.¿
or strangeastime haspassed.No siensoflateralsweeparcsecn.fn f.*
sh,eco'td benefitfrom a secondar-y f"r.",
MAcs_Iift,*rrrlf ,rfilg", "i"].J. ,¡.
samecorrectioni¡ the verticaldirec:tlon and p¡ovide
a ¡atural youngerlook
tbr 8 ro I0 years.

DIFFICULT CASES
A big parr ofthe learningcurve in facialrejuvenation
surgeryconsistsofthe
ability ro predict which rcsulr can be obtained
uring .irt"in ;;;;jo;. ,"
Forinstance, in padents with thi.k h.";y"
,ki;,;:o;:'rlff.._
:.i:-h,li:1.1
surrrsnarderto.obr¿irthanin padcnrswirh fhin
skinand6newrinkrcs. simi_
rarry,oeuer resuttsare more difñcult to obtain
in patientswith round, full, fat
faccscomparcdürh patientswho have mo¡c
slcnderfaces.In th... ca..r,
smallmodificationswill haveto bc included
tn oUr¡n J".o.iiJr"Of"'*_
sult. CouDsclingis extremclyimpoftatt with thescpatients
to d",.rfnir,"'i¡"o
Ievclofexpectation.Thc difficult patient t .*p..i"tion"
,igni;."riiv irlg¡.,
",
than what can be deliveredwith thc surgeon,s
¡tandardtechnique.Sometimes
b . bringthepatient's
ll yr: expecratlns
<town
," , ;;;; ¿;¡t;;j;;.,i;,
^orc complicarcd
and risky
surgery.Otherwise,thcriskof
:::i:,,o1*99""'ng
crcanng a dlsappotnred
paticntincrcasesifthe final rcsultdoesnot i.¡lfill his or
rcf expectanonsl hc cxperienccdsurgeonknows
that in somepadentsa pcf_
rc,crresulrrs srmptytechnically
impossible, regardlcss of rhe techniqueuseO.
r nc goarot evcryacsrhctic
surgeryis a happypatient,not a spcctacuür rcsuir.
In the difficult casesdescribedon the following pages,
it wascxplainedto the
patientswhy a specracul¡r¡csult would be ha¡J
to ábtain.
r46 Sh(trt.Sc$Ficc.Liti Techniques

Aestbetic Analysis
'fhis
S5-ycrrrold womal presentedwith thc f'ollowingsignsof an aging tircc
with thick scbaccousskin on hearryfbcill firturcs: a tired look, r,eq' m¡rkcd
nasohbialfblds,andsorre;'orvlingrnd laxityin tl'rcccrvicomentalangle,which
appcaredto be pure skinexccss. Shchrd prcviouslyundcrgoncan upperblcph
aroplastJ,clscq'hcre that rvasoflittlc or ¡r<)bcncfitin correctingher tircd l<xrk.
Thc plticnt las a smoker.

This proccclurcrvasdone under loc¡l ancsthcsia

with intramuscularrrrid¡zo-
'fhc
lam rclaxation(3 mg) and took 2 hours 20 minutcs. patient u'os dis-
chargccl2 hor.rrs
aftersurgcrl'.

Nonsurgicnl Plan
Thc trcatmentconsistcdof:
. A skin careregimenwitlr retinoicacid
. Infbrmatiol about thc dclcteriouscf]cct ofsmoking on thc fircial
skin

Surgical Plan
Thc trcatmcntconsistedof':
. Submcntal andjowl liposuction
. An extendedMACS-lift
. A lower pinch blcpharoplasty
o A short-scartemporallifi

TI'rcprticntrcsunrcd
socialactivitics
iu 4 wccks.Thisis morethxn.r\¡er.lgc
¡nd
cirnbc clpcctcdltcauseof thc hcirwlntl thickfhcialskin.Thc cclcm¡of rhc
c¡'clicis
u'ascspccialll'
long stlndirrg.
I t c l i . i u ü . \ 1 4 ( 5 L i i i T r d r n i q u c¡ r l l ) c 6 ¡ i n S1 $ L i n r i r \ I47
148 Shorr-Scd Facc-Lift T€chniqu.s

Pottoleratite Resaltt
The patient is shown I0 months postoperatively.On fiontal view, the shapeof
the face haschaagedfrom rectangular to mo¡e oval afte¡ cor¡ecting the jowl-
ing and improving the mandibu.larborder, The marionette grooveshave faded
and the effect on the nasolabialfolds is quite ¡ema¡kable.The midface is ¡e-
plenished with a diminished nasojugal groove and reduced vertical height of
the lower eyeüd. The lower eyeüd skin seemstighter Ptosis of the tail of the
eyebrow is nicely corrected without changing the position of the medial part
of the eyebrou The skin tone and texture are improved as a result of the
¡etinoic acid skin care treatment,

In the oblique view, note the effect on the neck, mandibular definition, and
especiallymalar volume rcsulting from the third suture placement.T¡ansition
of lower eyeüd skin into cheek skin is diminished. Note also the h.igherposr
tion of the lateral part of the eyebrow and subsequentcorrection of the tem-
poral hooding, which can also bc appreciatedin the profile üew.

If no temporal lift had been added in this proeedure, bulging of the hcary
thick ski¡r in the paratantha.lregion would defi4itely have occurrcd, creating
an aestheticallyuoattractive ¡esult. The qualiry of her temporal hairline scar
enablesher to we¡,! her hair back, leaving the au¡ide f¡ee.
I t r h f i n g ¡ r t \ 1 , \ ( S I t i l r . h f , t L r .t rr ¡ l ) . l i f r r g I ( . l . i r r i ( \ r19
150 Short Scd FaceLift Techniques

AestbeticAnalysis
This 49-year-oldwomanpresentedfor facialrejuvenátion.Shehad very hear.y
facial tissues,an obvious skin excessin the neck, moderatejowling, downward
slantingof the corne$ of th€ mouth, very markednasolabialfolds, midcheek
hollow, empty infraorbitalregionswith looselowe¡ eyelidskin, upper blepn-
arochalasis with fat herniation,and heary eyebrowswiti a drooping tail pro-
ducing temporalhooding and midglabellarand ftontal f¡owns.

This procedurewas done unde¡ local anesthesia with int¡amuscularmidazo-

lam relaxation(3 mg) and took 2 hours and 40 minutes.The patientwasdis-
charged2 hours after surgery.

Nonsurgicnl Plan
The treatment consistedof:
. A sKn careregimen with retinoic acid
. Botulinum toxin in corrugator and medial frontalis muscles

Sargical Plnn
The t¡eatmentconsistedof:
. Submentalliposuction
. An extended MACS-lift
. Microfat graftingof the nasolabialfold with abdominalfat afte¡
freeingthe fold with a picklefork (cannula)
¡ A lowerpinch blepharoplasty
. An upperblepharoplasty wit¡ fat resectionin both compartments
. A short-scartemporallift with galeapexy
l ( . ¡ n i ¡ g ¡ L r ., \ l \ ( l S J r l l ¡ . h . i ( t u r . r r r ¡L ) . l i i r i ¡ gl r I i n r t r \ l5l
r52 Shorr-Se. Fac.'Lift Tehniqu.s

Postoperethte
Rasalfr
The paticnt is shown I ycar postoperatively.He¡ facial volume is obüously af-
fected. The cervicomcntal angle is improved. Thc mandibular bo¡dcr has bet-
ter dcfinition and jowling is co¡rcctcd. The effcct on the midfacc is ¡emark-
able: the nasolabialfolds are softened,the midcheekand inftao¡bitalhollow
are corrected, and the transition from lower eyelid skin into chcek skin is im-
proved. Puf! upper cyclids are corrected and thc tail ofthe eyebrow is reposi-
tioned to correct lateral hooding. Thc latter is bcst secn asa changc in curva-
ture ofthe cyebrow in the oblique and profile üews, The combination ofver-
tical lifting of the malu fat pad and subcisionwith lipofrlling of the nasolabial
fold works synergisticallyto almost completely efface the fold. The profile
view also showsa good but not spcctacularresult on the ccrücomental angle.
This resuln &om true skin excessin tllc neck and might have been bcfter cor-
rectcd by more extensivelyundermining the neck. Most of the rcjuvenating
effect in this patient is the result of changesin the midface. The flnal sca¡ is
about l0 cm long and ofgood quality. The sca¡stops at t¡e cadobe and thc¡e
was no refoauricular dissection.
ll.h¡if! ¡r. lll( \ l r l r l r . r f r r L ! r¡ r i ¡ l ) r r r i ! 1 l i \ I i i r i i r \ 15.3

I
Í
 s h n r F s L ¡ r t s i ( e - L r f tr e c n n r q u e s

Aesthetic Analysis
This 63-year-oldwoman presc¡ltcdfor facialreluvenationwith minimal inva-
siveness- Sheaskedif shc could bclcfit from laserresurfacingalone.Shehad
thick, elastoticsun-damaged skin with deeprhltids and groovesdown to hcr
sternalnotch. She had skin laxity in her neck with obviousplatysmalbands,
jowling, and a ptotic sr.rbmandibulargland;and a deepnasolabialgroovewith
concentricrh¡ids toward thc chcek. She showed a midcheekhollow and
markedeyelid-cheek junctionalgroove.Shehadpreviousuppercyclid surgery
andshoweda temporalhooding with ptosisofthe tail ofthc cyebrow Shealso
had markedglabellarlincs,

With carefulcounselingwe were ableto explainto thc patientthat laserresur-

ñcing alonewould correct part of thc fi¡e lines and rhytids, but would not
correctthe skin l¿{ity and the volumechangessheprescntcd.

This procedurewas donc undcr local ancstlresia with intramuscularmidazo-

lam relaxation(3.5 nrg) and took 3 lrours.Tlre patientwasdischarged2 hours
aftcr surgcry.

Surgiaal Plan
The treatmentconsistedof:
. Submcntalliposuction
. An cxtcndedMACS{ift
. Pcrioralerbium:YAclascrrcsurfacins
. A lowerpinch blepharoplasty
. A shot-sca! temporallift by galeapexy
. Poste¡iorcervicoplasty(seeVolumeI, p. 210)

Shereñlsedanytreatmentofthe glabellarfrown linesa¡d wasvery upsctwith

the "long recovery"(4 weeks).Shcwascventuallyhappywith thc rcsult.

t:'
R (f , . 1 Cr l , eM n ( \ | r l t c h n r . , c J r d ¡ e l n r n g t , . t i m i N
 l5ó Sfiort ScarF¡cc ¡.iri TcchDiques

Postoperetive Resalts
Thc patientis shown l4 monthspostoperativelyIr gcncral,tltc resultsshow¡
vcrv DaturalreiLrve¡.1tion with alr obviousshift in volurncdistributionwithout
a¡ "opcratedlook." Becauseofthc bad skin quality,r'crticalskitrfolds appear
in the infral<¡br¡lar lateralneck regiorrnccessitating a postcriorccrvicoplasq,.
'fhe
rejuvenatingcffcct in the neck is seendorvn to the sternalnotch. (lcrvi'
comcntallaxirylnd platy.smal bandslrc rvellcorrectcdalongrvith the jol'ling,
lhich contributcsto improvcclclefinitionof the nandibr¡larborder. B¡' sus-
pending; thc htcralpart ofthc platysmrin a verticaldi¡cction,the ptoticsub-
mandibular glmd is shiftedto its originalposition.Thc miclchcck andinfi¡ror-
bital holkxv xrc nicclycorrected,thcrcbyfadingthe eyclid-chcck junction.
-fhe
Iorvercyclidappcarsshorterin vcrticalhcight and tlre tr¡nsition of'q/clid
skin into chcekskin is smoothcr'l'l'rc tcnrporalhooding is corrcctedand thc
shapcof thc cycbrorvshou,sa more yoLrthf'r¡l straightcrcurvc bcc¡uscthc lat
cral pcrt is lificcl. Thc profilc viclv shows:ln obviouscorrcctionof borh rhc
ccrvicomcntllanglcand platysmllbrntling. The dorvnwar<l-grzing viervshorvs
not only tl'tcstatrility ofthe corrcctionin thc neck,but alsoin thc wholcfacc.
'flrc
aclcquatc qualityofthc scarsis sccnin thc dctailccl viewsofthc 6nalsclrs
i¡r thc prcauricular, tcrrporal,ancloccipitrlircas.
-fhis
c¡se rvasdiflicult bccausethe p¡ticnt rvasvcrv rcluctant to undcrg()
surgcr1,.Sl'rcthought shccould lrc hclpcdl,ith lascrrcsurficingalotc. Thc st'
lution w¡s to of-flr hcr a coml¡inatit¡¡lof simplc,cffcctivc,lnd s:tfeproccdurcs
th¡r wl'rrltlgivchcr rrn¡tur.rlrcjrrvcnrti(rr.

¡F7'=-
L i i r r : 1 r r !\ l \ 1 \ t r !.tr.i,trr.rt l).rtr r:lr\l |f. l;,

f"
,/
f58 Shor¡ Scar!'aceLift Techniques

Aestbetic Analysis
This 5ó yearold womar requestcdtotal facial rejuvenationto include the
neck,midface,eyelids,and eyebrows.Shealsowantedthe nasaldeformityand
üe protruding earsco¡rected.l{er main concernwasher ti¡ed look. Shepre
sentedwith moderatenecklaxity,jowling, marionettegrooves,and rasolabial
folds. Shehad an empty midfacewith a markedjunction betweeneyelidand
cheek,looselower eyelidskin with fine rhytids,and an obviousupper bleph-
arochalasiswith a drooping tail of the eyebrow.Her nasaldefo¡mitiescon-
sistedof a dorsalhump and a wide dorsum,with a broad undefinedtip. The
auriculardefirrmity is obvious.

This procedurewas done under generalanesthesiaand took nearly4 hours.

The patientstayedovernightand wasdischargedthe next day.

Sargiool Plan
The t¡eatmentconsistedof:
. Submentalüposuction
. An extendedMACS-lift
. A lower pinch blepharoplasty with discretefat ¡emovalfrom me-
dial and mediancompartments
. An upper blepharoplasty ütl, skin,muscle,and fat removal
. A short-scartemporallift by galeapexy
. Open rhinoplastywith hump removal,lateralosteotom¡ and tip
rhinoplasty
¡ Correctionofp¡otruding ears
R .f , r ' ! , h ( ^ l \ , \ - l | f r f , i ü ' c r , u L r ( r , i , . g t r , t , , , , , .
 I l¡0 \ r , 1 \ . t r rf r . . J i l r l ( . r , r r . ! 1 , ( \

PostoperatircRcsults
T h c i ¡ ¡ t i c n ti s r h o l r r I \ c . l r \ l ) ( ) \ t ( ) l ) c r . t t i \ (\ \l \' (. . ¡ n \ c c ¡ s t i r b l ¡ r . ( ) r r e . t i (' i) n
thc ccr\i.omcnt.rl rng.lc.j()\\ling. nr.\fi()nclt(qr(x^e\. in(l nis()1¡Lriilti)1(is.
t r l r s rr ¡ l l i r ¡ L r iss t h c | c r i o c r r l ¡ rr c i L r \ c n . r t i ( \, ni t, l t . r\ t f i l i i n ! lc l t ( . r ( r n t h c n r i ¡
l ¡ c c .c v c l i dc h c c kj r r r r r ' I i o r r . . rrIirS( I, l r t r r c( \)\l r l r c1 ¡ ¡ v c cr r c l i i l\ l ( i n\ i t h o u l r n v
( h . r r g ci n c \ c l i ( l¡ l r s i r i o n .l h c l c J u n ( i . ¡ r Li r l ) l ) r r c v c l si tlii i r rh . r rl r c e r r c r r r o r c t l .
llcl.ositioning.()l rhc l)l()tic c\ct)r()\\ r.ril s.rs nrrn,il¡¡r'r L.ct¡uscoi¡he lorv
| ( ) s i t i ( ) n( ) i t h c c v c L ) r ( )¡\ r\ r d l h c ( ) h v i o L rt c\ n r p o r ' .hr lo r r l i r r s . \ n i s o l . r t c ci lr
t c ¡ L l e Lt lr l A ( l Sl i l t l o L r l t l c l c l i n i t c lhi . r r cI r ' o r o l i c trl 1 < i n L r L r r e h i ni ng t l r c p . r r . r
.¡nlh.rl .rrc.r.\hiih ..rrr niccl\ bc ¡or'r'citerllrr .r sltolt sclI tcnrPo|rl lilt. lhc
c ( n - r c . l i ( )or rl r l r c r r o s c . l | l ¡l l l c c . l f s¡ ¡ ¡ ¡ l r ¡ . t l ) ¡ r ' c c t . t t cN t l ( ) l c . t l s ( t)l t c g ( x x l
q L r i r l i no f r h c f f e ¡ u r i r u l x rx n ( 1l c r r l ) ( ) r ' .hr,l l i f l i r )se. . r r .

l I c t l i l l i c L r l tirn t h r sc ¡ ¡ c \ . r s r h c . ¡ ) r r ) l ) 1 . \ i ro\ l e o n r h i n i n qt l i f l i r c r r r¡ r r o c c
r i u l e s l. l c c ¡ L r rocl t h c t i n r ec l l i ( i c r r ( \¡ ¡ l I l , \ ( S l i j l s r f u c f \ ,( ) l l r c ri n ¡ c r r c r ¡ t j o r r s
\ r r . h . r sr h i r r ( ) l ) l . r s¡ r1r\( l f ) r ( ) 1 ( ) l ) l , l \¡to\ f l t i l r c i n e l U L l ciLl ll t h c s . r t I co I c r ' . t t i r c
l i r r r c .l t i \ ( ) u rc ( ) r r \ i a t i ( t)lnr . r \l L r f l l c f i (l\( ) n L l ct lf l . l l t . ll t ¡ ¡ L l llr¡ c c r ¡ n tlcr r ¡ r i l t gl o l
l l r r s r r r ! . c ( ).rrrr t l . r r c r t h e r i ¡ r I r $ r.sr nt r i¡ o t e n t i , r l l irl e r ' i n r c n t . lrilr r t h c ¡ . r t i c r
\ \ ' i l h r r t h i st i r n c ,n r , l n vs u f q e r i e s . . lbt e e r ¡ ¡ t h i n c t l

E.
l{dlii,rilrlrrIl\( J i i L l i . h r n t L r . L i r lt ) . h ¡ i f S J ¡ l L . r n Tó1
162 Short scd F¿.c Lift Tcchniqucs

AestbeticAnaltsis
This S3-year-oldwoman askedfor fhcialrejuvenationwith minimal invasive-
ness.Shewo¡e he¡ hair short and did not wa¡t anv scarbehind the ear.Shc
presentedwith laxity in the neck with platysmalbands,jowls, marionette
grooves)fine perioralr\tids on thin lips, a ma¡kednasolabialfold, and an
empty deflatedmidfacewith obviousdemarcationbetweenchcekand eyclid.
She also requestedcorrection of her ¡asal hump, hanging columclla, and
breasthypoplasia,

The surgeriesweredonewith two teams(one facialand one breastteam)with

drc patientunder generalanesdresia
and took 3 hours.The patientstayedover-
night and wasdischargedthe next day

Sargioal Plan
The treatmentconsistedof:
. Submcntal liposuctiori
. An cxtendcdMACSlift
. A lower pinch blepharoplasty
. Microfat glafting ofthe nasojugalgroove(L cc^ide), zygomatic
arca(9 cclide), upperlip (5 cc in velmilion and whole upperlip),
lower lip (3 cc), nasolabialgrooveand cornerofthe mouth (1.5
cc,/side)
. Uppe¡ lip e¡bium:YAGlascrrcsurfacing
. Open rhinoplastywith hump reduction,tip rcfincment,and cor-
rection of the columellar-alarrelatíonshio
. AugmentationmastopelT
srm''I srl ?!tr¡g.O PUr.¡bruqr{ n¡t SIVW )qr tiutr,¡l.I
164 s h ( r 1 s . r Ll r . r r i t i r . . h , n t , L c !

Postopcr¡tti1,e llesu lts

l hc I).lticr1t
is sh(^\n l0 months l.ostrl¡cr,rlilcl\'.'fhccrflv |()sl()l)cr.rrr\c \rc\!s
slrol tl¡c crt¡¡ molbiLlin'of lipohlling .rlrcr 1 rnd 3 r'ccks. lhc fin.rrrr:srrrrs,
lrolcrcr'. shol h<xr lcrr'¡r'dinqthis.rrLlirion.rl prrccdurc crrr bc. l{csultsslr(^r
()1
s¡tisfictofr c()r'ccti()n lhc ccr\ia()rncrrfirl .!rglc, jorvls, t¡ri()ltcttcSr(x^cs.
Ir¡sol¡lri¡llirlcls,.rrrtlrrrrobr ioLrs|c¡rlcnishnrcut ofthc nridl.lcc.This crn t)c t)csr
sccrrirr lllc olrli,.¡Lrc
vicN iD \\fiich thc flrt zlg()m.r1i..lrcilis tr.ursli)rnrcri
rnl().1
highlightcdvoLrthtirlnr¡l¡r'cnrrncncc. l'hc clclid .hcck jLrncli()nis lidctl. l hc
Lr¡pcr.rndlolcr'lips rlc n¡tLl¡llv ¡usntcntcrl¡nrl linc ¡hlticlsrrc cr¡dic.rLccl Lrt
1hc l.rscrtrc¡tr¡cnt. l hc r-hinr4rl.rsrl h.rs.r conr¡rlcnrcnt.rrv rcjLrvcn.rrin,l
cllr'cr
()lr lhc ()lhcr surgcfics.

l h c i l c L . r i l c cr il t r o f t l l c l i n ¡ l s c r r - s h r ¡ r sl h ¡ 1 l h ¡ t \ . ¡ f c i n c o n s p i c u o u sl i t l t . r
s h o r t l r . r i r c r r tl.r r c r l l l ¡ c n t h c t c l t p ( ) f r l h r i t s r t - c ¡ u s h c d . r \ ' ¡ r , t h c t c l l l ) ( ) r . r l
ffch.riflirrc \c,rf ir hrr¡tllr visiLrlc.

l l l e ¡ . l i t l i t L r litnv t h i sc . r s c\ l \ 1 h cc \ 1 r . .r r L r q n r c n r , r rric( )r r¡ rL r i r ci n r l t ) r i l ti l r i r r¡ l
t i c l l \ \ i t h J i c i . rhl r ¡ l l o r r i n qñ.l i c r o l i t ! . r , r l i i n c\ \ . r sr l c l i n i t c l trh c b c s tr r l j L l r c t i
s ¡ r l L r t i or n d o l i i r c t l r r e o n r p l c r r r c r vr t r r' c j r r r c n r t i ol nh ¡ t ( ¡ n n ( ) t l ¡ c o L r t . r i l r c r l
h v e l ¡ s s r c .Jrill i i n gp r o c c t l t r l c. sr i o n t .

l l r i r p . r t i c n t¡ l s o c l c n r o r ¡ r l ¡ l c st h ¡ l ( l i l l ¡ f c n l s L t r t t c r i ccsx n c l s i l l b c e o l l b i l t c t l
r r i t l ¡ i n . r r c ¡ s o n ¡ b l ct i l l c s e l r c d L L l c .

3 weeks pósropefatve y 10 m.¡llrs poslopcrativ.y

{ r r r r . : 1 1 , \. l \ 1 \ I I L , , l rr , Lf . r r ( i l ) , l l ¡ r ! . l r ! . I r ' t65
róó Short-sca.Face-LiftTechniquca

Aestheüc Attolltsis
This óó-ycar-old man prcscnted for a facial rejuvenation procedure after his
üfe had a sccondaryfacclift by alr extendcdMACS-lift. He had neckskinlax
ity with markedfolds down to his occipitalregion,jowls, marionettcgrooves,
nasolabialfolds, an empty midface, and lower blepharochalasisüth an obu-
ous fat herniation. Two yean earlier he had an acutc myocardialinfarction and
a yearlatcr a stent wasplaccd in his right coronary artcry. He is under anticoag-
ulation thcrapyand smokesI packofcigarettesa day,

This proccdure was donc under local a[esthesiawith int¡amuscular midazo-

lam ¡elaxation(3.5 mg) and took 2 hours and 50 minutes.The paticnt was
dischargcd2 hours aftcr surgery.

S*rgic*l Plor
Thc treatmentco¡sistedof:
I Submcntalüposuction
. An sxtcndcdMACS-lift
. Postcrio!cervicoplasty(seeVolumeI, p. 2I0)
r A transconiu¡ctivallowcr blcpharoplasty
üth pinch skin rcscction

PostoperaüwRasults
The patientis shown I yearpostoperativcly. The most striking result is in tic
midface-thc nasolabialfolds are improved, the infraorbital hollow is rcplen-
ished,thc verticalheight ofthe lower eyelidis shortencd.He had a slight re-
lapscofhis cervicomcnralanglc, but good correction ofjowling and bcner def-
inition ofthe mandibularborde¡.The posteriorneck skin is redrapedposten-
orly tirough an occipitalprehairlineincisionto co¡rcct the verticalficldsthat
appearedat the infralobular region after an extended MACS-Iift. Although all
procedures were minimally invasivc and subcutancousdissection was limited
to what wasstrictlyneccssary, a smallwound dehiscencc occurredin this high-
risk case.The smallareaofsKn necrosis healcdby seconduyintensionandleft
a smallatrophic scarthat was hardly noticeable,cven with his short haircut.
The occipital prehairlinc scar healed wcll. We were able to ofler this man a
substantialfacial rcjuve¡rationwithout too many risks. In view ofthe small area
of skin ncc¡osis in tiis case,more aggrcssiveundcrmining and extensivedis-
sectionwould definitelyhaveinc¡easedthe ¡isksof evenmore necrosis.
 l l l . r , i r i g¡ ¡ ( I t . 1 . \ J . i r L f i I j : r t r L .t r , r t t ) d t j L r j gl r . L L ¡ r j : \ 167

t
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168 F¡ce-LiftTcchniques
Short-Scar

The Difficult Nasolabial Fold

AestheticAnnlysis
This S3-ycar-old woman lost ó0 kg after gastric bypasssurgcry and was diag-
nosed üth depersonalization.Thc woman she sawin the mi¡ror did oot co¡-
respond with üe person she felt she was. Her cmpty midface and healy na-
solabial folds we¡c especiallyproblematic for her. Thc skin laxity in her cheeks
and neck when looking downward wasparticularly distrcssñrlfor her.

This procedurewas done unde¡ local anesthesia with int¡amuscula¡midazo-

lam relaxation (3.5 mg) and took 2 hours and 30 minutes. Thc paticnt was
discharged2 houn aftcr su¡gery

S*rgical Plan
Thc ueatmentconsistedof:
r Submcntalüposuction
. An cxtcndcdMACS.lift
. A lowcr pinch blcpharoplasty
. An uppcr blcpharoplasty
 llttirL¡g¡¡r ¡1.{(l\ l.iir li.hfiqu..rir.r l)(lirrrr! l¡ I fir. l a,9

*
¡}

1
).70 s h o Í S c a rF a c el . i l i ' l t c h n i q u e s

PostoperathteResubs
Thc prticr-rtis shorvn I and 3 yerrs postoperirtively.The slbment:r1skin exccss
is corrcctccland tl-rcjarvlirc definitio¡ is improved rvith correction of the mod
cratc jorvlilg. Most remad<¡bleis thc very stable correction of the nasolatrial
fbld with good replcnishmcnt ofthc miclfaceancl iorvcr eyelid region. Note
the improved sl(in turgor in the cheeks.The transition ofkrrvcr cyclid skin intcr
chcekskitrsecmssmootherar]dthe vertic¡l height ofthe lowcr eyclidappcars
tc¡be rccluccd.

ln thc p¡ofile viclv at I year, she docs not r¡ind u'errin€i he¡ hair l¡¡ck in thc
rctro:ruricuhr rcgiorr bccarrc thcrc is no rctroxrrriculir scarto bc hidden. Conr-
p:rrisorrofthe dorvnu,lrd-gazing ¡rrohlc view bctn'ccn I and 3 vcars rcvcals ¡
slight rclaxationofthc subr¡entalskin, but it is still a nicc irnptovctttcntcolt't
¡Tlred rvith thc prcoper¡tive vicw. Tlris paticnt \v:rstrcatcd bcfirrc wc st¡rtcd
nricrot'htgroftingar,dshort-sclrtem¡rorallifiing. Othclwisc,thcscwould hirvc
lTccnpcrfirn'nccl ls lvcll.

3 ye¿rsposlope atively
 I:]

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3 !.n,! !:il.t].ral!. y

I
172 Short scar FaceLiftTechniques

AestbeticAnalysis
This 48-year'oldwomanpresentedfor facialrejuvenationandwasmainlycon-
ce¡nedwith he¡ deepand long nasolabialfolds. Shehad neck skin laxity with
moderateplatysmalbandingand submentalfatty deposits,moderatejowling,
and very deep and sharp nasolabialfolds extending into the marionette
grooves.Shehad thick oily skin,an infraorbitalhollow, a markedeyelid-cheek
junction, and fat herniasin tlle lower eyelids.

This procedurewas dotre under local anesthesia

with intramuscularmidazo-
lam relaxation(3.5 mg) and took 2 hours and l0 minutcs.The patient was
discharged2 hours aftersurgery.

Sargiaal Plan
The üeatmentconsistedof:
. Submentalliposuction
. A¡ extendedMACSJift
. A lower pinch blepharoplastyand tranSconjunctivalfat removal
. Subcisionand microfatgraftingof dre nasolabialfolds (2 ccftide)

Postopara,rit
a Reswlts
The patientis shown I2 monthspostoperatively. Correctionofthe subme¡tal
rcgion and jowls is good, Most striking is the very effectivesofteningof the
nasolabial folds,which is a combinedeffectofmidfacialliftilg via the third su-
ture, the subcision,and the microfatgrafting.Eachofthese maneuveÍssepa-
ratelycould neverresultin a comparableinprovement.The lid-cheekjunction
is fadedand fat bulging ofthe lower lid is corrected.Note the good quality of
the preauricularand temporalprchairhoescars.
l { . i i ¡ s ¡ i r . ¡ 1 . \ ( l s J i r Li i . l r r i r t r . r r ¡ l ) r l i r L r g t r \ r . n , ( ,
Shóit Scd Face üft Tech¡iqúes

The Prominent Submandibular Gland

AestbeticAnalysis
This S9-year-oldman presentedfo¡ a facialrejuvenation.His main concern
was submental laxity and deep nasolabialfolds. He had submental skin laxity
with platysmal bands and jowling, which were mainly obvious in the down-
ward-gazing view. Also note the prominent submandibular gland on the left
side,He had deepnasolabialfolds,a hollow midcheek,distensionof the lower
eyelid.anda degreeofblepharochaJasis.

This procedurewas done under local anesthesiawith intramuscularmidazo-

lam rela-xation(4 mg) and took 2 hours.The patientwasdischarged2 hours
after surgerv.

Surgiaal Plan
The treatmentconsistedof:
. Submental üposuction
. An extendcdMACS-lift
. An upperblepharoplasty
. A lowc¡ pinch blcpharoplasty

PostoperaüveResults
The patientis shown8 monthspostoperatively. The facialcontouris improved
toward a more oval shapewith better mandibulardefinition. The nasolabial
groovesand concentricexpressionrhltids are diminished,the midfaceis re-
plenished,the inflaorbital hollow is corrected,and his lower eyelid skin rs
tightened.On the profile view with downwardgazing,submentalskin laxity,
jowling, and deepfacialgroovesarecorrected.Note the inconspicuous preau-
ricularandtemporalprehairlinescars,the correctpositionofthe sideburn,and
the absenceofhair growth on the tragus,the ¡esultofvertical skin redraping.
In the obliqueview,note the cor¡€ctedplatysmalbands.Submandibulargland
bulging is corrected,¿ttributableto improvedsupportprovidedby the cranial
suspension ofthe lateralplarysmalborder.A markedvolumetriclifting effectrs
seenin the midfacewith a harmonicoeeecurveon the contralateralside.
 L t . l ¡ i , 1 Ij . I ¡ \ ( \ l.lt:1..¡r rtrIIrl L ) rj j r l r : l r \ I r r | L r 175

t\'

T
I
tq ,f;i,.rt, \

r
short-scafFace-Lift Techniqúes

AeaheücAttolysis
This 43-year-oldwomanpresentedbccauseofprecociousfacialaging.Shewas
very concernedabout her'sad look." Shealsoaskedfor a nasalcorrection.

The patient had a poorly definedfacialshape.The frontal view showedquite

pronouncedjowling for her agc,ptosisofthe midfacialvolumes,and thin un-
delir:edlips. In the obliqueview,tie most striking featureswerejowling, na-
solabialand marionettegrooves,and an increasedlength ofthe lowcr eyelid.
Shehad ptosisofthe tail ofthc cyebrowüth temporalhooding. The profile
view revealcda blunt cervicomentalanglc,weakchin, and marioncttcgrooves.
Her nosemainlyshowedtip ove¡projectionand a hypertrophicnasalspine.All
ofthcsc factorsalongwith hcr facialinbalancecont¡ibutedto thc difficultyof
this casc.

The paticntwastreatedduring thc Controversies,

Art, and Technologyin Fa-
cial AestheticSurgery(CATFAS)mecting in Gent in 2004. This procedure
wascloncunder generalancsthesiabecausea rhinoplastywasalsoperfbrnred.

Notts*rgical Plan
Thc trcatmcnt consistedof:
. üpofilli¡g of the lips undcr local ancsthesia¿t a latc¡ timc

Sargicatr
Ptrar
Thc trcatmcntconsistedof:
. Submental (by Dr. AlexisVerpaele)
liposuction
¡ An extendcdMACS-üft(by Dr. Alcús Verpaelc)
. Fogli tcmporalüft by fasciapexy(by Dr. Alain Fogli)
. An upperblepharoplasty (by Dr. AlcxisVerpaele)
. A¡ opcn rhinoplasty(by Dr. Gilbert Aiach)
. Chin augmcntationwith RestylancSubQ(two x 2 cc; by
Dr. AlexisVerpaelc)
. Lip augmentationby microfatgrafting8 monthspostopcrativcly
(by Dr. AlexisVerpaele)
Itefirinq d,r j\L¡\CSI-itt Tcchniqueú Dcfiningfts t.¡¡irs
178 shor¡ Sctrr!¡ce Lili Tc.hniqu(s

PostoperetiveResalts
Thc paticnt is shorl'tr I xnd 2%,vearspostopcrativclr,.A gc¡ler¡l improvement
ofthc licial aestheticsis seen.The fiontal vicrvs shorv a ¡r¡rkeci improvement
of thc lorve¡ facicl appearance,shifiing from a rathcr dull rectangular to ¡
ple:rsingoval shapc rvith a well defined nr¡ndibulxr bordcr. Thc jorvlirg ntl
marionette groo\¡es are corrcctcd, thc nasol¡bi¡l folcls ale softened, and thc
chccl$ ancl the infiaorbital hollou'arc rcplcnishccl.

The oblique view sl,ows tretter definitiol of thc manclibul¡r Lrorder :rnd thc
liftctl position ofthe corners ofthe nrouth. Notc tllc vollrmctric rcstor¡tion of'
thc fici:rl ogcc ciruscd by the vertical repositioning of lolvcr fircial volut'llcs.
'l'he
Iitl-cheekjunctio¡ris wcll blcnclcd.Also notc thc lifted positionofthc tiril
ofthc cyebrou,:urdthe r.rnfbldcd tcm¡rorirlrcgiolt.

In thc proJileview,stablccorrcctionof tl'tcsubmcntalarci c¡n be rppreci:rtcd.

Ohin lltrgn'rcntltiou rvith llcstylanc SutrQ lastccl nrorc th¡n 2 yeirs widrout
tolrch'up. Thc colÍcctioll of thc n'r¡ri(nlcttcgroovcsand thc midflcc lif'ting
rrc stlblc. AIso notc rhc go<xltltrirlity()f thc scilrlnd thc ¡¡ood volurttc itrtcl
¡rlojcctionofthc li¡:rs.
Thc ovcrprojcctccl nnsll tip is corrcctcd.

27, yearspostoperanve
y

=
llf r r i l t l r r ¡ 1 1 ( 1 5I L : l l i . . r , r r ! u r . f r l L ) . t i r L . !l r \ I r r r i L r \ t;.)

! Ett. 1
{

r , ve¡ 5li!!n)|I] ¡r !.!

r80 shorr-Sce Fa.c Lift Techniqucs

Sargical Peorls
. Avoid openingthe neckifpossible.
. In the neck asin the face,thc vertical vector is the rejuvenating one.
. Secureplatysmasuspension is essential
for long-term correction,
. l¡ss is still mo¡e than enoughin most cases.
. Sutures are o¡ly necessaryfor temporary stabilization ofsubcutaneous
sculpturing work.
. The long-termstabilityoft¡e correctionis not dependenton the slrture
but on thc combinationof subcutaneous sculpturingtechniqueswith
parallel vcrtical redraping and rimming ofthe skin.
. Use the third malarsuture:lifting the midfaceprovidcsa foundationto
the lower eyelidand completesfacialrejuvenation.It stably¡eposirions
the malarfat pad in its originalpositionwithout risk ofovercorrection.
. All verticalfacelifts needa temporalprchairlineincisionto avoidraising
the sideburn.
¡ The MACSlift cansafelybe usedafteranypreviousfaceJiftprocedu¡e,
. Evenin difncult casesthe MACS-lift is a valuableoption.
. Somepatientsdefinitelynecdadditionalvolume.Microfat graftingis an
elegantmethodofstabletissueaugmentation

BIBLIOGMIHY
AstonSJ,BernardRW,CassonP\ et al, Sccoldaryfacelift. Paneldiscussion, Aesthedc
S'jrgI 22t277-283,2002.
BakcrD, Mass¡haH, NahaiF, TonnerdPL. Sbort sc¡r hcc lift. Paneldiscussion. Aes-
thcticSurg, 25:ó07-ó17,2005.
CamirandA, Dor.Lcet J. A comparison betweenpaollcl hairlineincisionsand perpendicu-
lar incisionswhenperficrming a faceliit. l,lastReconstrSurg99r10-15,1997.
ColemanSB- Structural fat grafting: Morc than a permanentfiller. PlasrReconstrSurg
I l8(3 Suppl):S108-S120, 200ó.
ConnellBF, Scmlacher RA. Contemporary decplaye¡facialrejuvcn¡tion.PlastReconstr
Su¡gr00¡1513-1523, 1997.
E¡licsM, CottsteinU, Rohrb¡ch-Vo¡la,rd S, et al. Reductionofsalivaryflow with botu-
linum toxin: Extendedrcporton 33 paticntsütl¡ drooling,sal¡vary fistulas,and sial-
¡denilis.Laryngoscope I l4:185ó-18ó0,2004.
FcldmanlJ. NeckLift. St Louis:QualityMedicalPublishing, 200ó.
GroverB, JoncsBM, W¿terhous€ N. The preventio¡r of lraenarom¡followingrhytidec
tomy:A rcviewof 1078consccutive facelitu.B¡, Pl¡stSu¡g54:481-48ó,2001.
I¡bbé D, Flanco RG, NicolasJ. Platysmasuspension¡nd platysmaplasry during ncck üft:
Anatomicalstudyand analysis of thirty cases. PlastReconstrSurg l),7:2001-2O09,
2006.
Paul MD, CalvcrtJW, Eva s c. The cvolutionof the midf¿celift ir aestheticplastrc
surgery.PlestReconstrSurg117:1809-1827, 200ó.
 Rclinirs drc MACS LiftTcchniqucind Defi¡ins l$ Linlits r8r

SingcrD, SullivanP. Submandibulaf gland Ir Ar aoatonriccviluirtiorlx¡d surgicalap-

proachto submandibular glandresectioo fbr fácinlrcjuven¡ti()r.PlastRecoDstr Surg
I l 2 : l 1 5 0 ' t1 5 4 2
, 003.
'lbDnard
PL,Verp¡clcA. 300 MACSlift shortscar rh)'tidcctonl¡cs:
AnÍl_vsis
ofrcsuhs¡tld
complications. Eur l I'lastSurg28:198-205,2005.
'l(nrnrrct
PL, Vcrp¡clcA. The MACS'Lift Short-ScarRhyticlcctorl!,. St Louis:Qu.rlity
Mcdical PLrblishing, 2004.
T(nrnardPL, VcrprclcA. Optinizing resúltsftom mil1iñ¡l ¡cccsscr¡ni suspcnsion lili-
ing (MACS-lift). AcsdlcticPlastSury29:213-220, 2005.
T()nnardlt, Verpaclc A, MonstrcvS,ct ¡1.M¡nimlllrcccsscrani¡lsuspcnsion lift: A modi-
ficclS'|ift. Pl¡stRcd(r1str Surg 109:2074-2086, 2002.
-l'¡rc
Vcrp¡cleA, Tonn¡rd Pt,, Pirayesh A, ct ¡1. thi¡d sutlrc ir MAcs-l¡fting: M¡k¡ng
nridt¡celiliing si¡nplcandsafc.J Phst RcconstrAcsthetSorg(¡n prcss).
 The MACS-Lift
Short-Scar
FaceLift
Technicoland,Strntegic
Consid,erotions
Mark Laurencefewell
184 s | l 1 1 5 . ¡ r l - . r . cI i i i l ¡ . ] r ¡ i , l u e \

D
-l\rlincmcnts ¡n.l ncrr trchniqucsin firci.rlrcjutcn:rtionsurgcrvrrc rcgul:uh
rcp(ntcd in thc litcr,rturc¡nd in scicnrilicfirrunrs.()n closcr cx.rnrrD¡ri.rn,
horvcvcr,m:url of rhcscnrcrclt'rcfrcscntincrcnrcnt.rlim¡rr'ovcnrcnts tu trist
ing tcchniqucs.Historie¡llr,,thcre hils bccn ir ¡rcnclulunrcficct trct\rccncon
vcnti()n¡lilnd c\trcrrcly inr¡si!c iippro.rchcs. \\'c ()ftcn scenrt()
In r'ctr'ospccl,
lrc r¡orc fircuscrlorr nrorinr¡bctl\'ccn(lif}ilcnt tcchnic¡lsolL¡tiorrs lhlu on u¡r
ricrst.rndin¡lhorv to cil.:ctirch ¡crfilnr tici.rl lcjulcnrrtionrrn .r (livcr\Lf.rri(n¡
l)()|ulJtr()n.
'lhc
short-sc:rrficc lifi lcprcsents.r tlcp.rrturcfirrnr this pcndulurr ¡nrl .r fruc
ildv.lnccirr thc cv()luli{)nof firciirlÍcjrr!crrirtio¡sürqcf\,.lr{)f llrc inn(^,¡tors()l'
ljris illtcfniriYcilppf()¡ch.it rcPrc¡icntc(l ln "Ah.r" nronrcnt,r'ct !cirrsI:r¡cr.d1c
crrrrrplctctlctirilsof this innt¡rrion rcrurin t() l)c lirlll rlclirrcrtcrl.Althou¡,h
|]l.l¡rvindi\'iduilshxvc bccr crctlitctlNirh rhc tlcrci4rnrcntofrllesll¡n1sc¡f¡p
l)¡[cl], l)irtrick lirlD.t|rl, Alcris \t¡p¡clc, ¡¡rtl l)¡nicl l]¡kcr h¡rc (ftrrc DrLrch
¡) ¡¡rrncc this ()pcrrtir¡n.()thcrs such.ls,\lcrr(lcls{rn, l}csins,L.rtrtrt,.rnrl(i¡r
dctl() hir\c l.rirlthc gloLrrrehrrrrk rritl) l.rciill¡r).lf(nrrrstLrriics tll¡t ll¡rc shorrn
horr rlc c¡r ¡clliclc liei¡l fcjLr\,cnirti()n Ihr()uLr.lr il lcssi¡rrirsircirPPr'o¡ch.
i \ l L r c ho l ¡ h i si s i r r c t h i t r l i i n og 1, - h o l ' t o r c ¡ o s i t i o ¡l i t i r n t lt l c c ¡ r c r ' l ¡ r c ¡r s' ¡ ¡ h c r
llr.lo !¡scsl(in-tiql)tcirr!.l)rocc(jLrrcr.

RETHINKING THE APPROACH TO FACIAL

REJUVENATION
As srrrgconsrvc sonrclinrcsl)cc()r'¡cnrolc crr¡nrorcrl()f:fhclcelrrric¡l¡spccts()1'
llrc ()l)cr¡ti()ns \vc pcrlirÍnr thirn ol'thc goirlsrvc ¡rc !r!in!, l().rcl)ir\c,.rndlcss
rrincllirl ol thc linrit.¡ti<¡¡rs thiu b¡f !¡\ tio¡r .rtt.rirrioglhcrrr.Wc cr)¡)r l.rl(iog
t l l i ¡ S s . l p ¡ f t¡ r l ( l t l l c n r c . l s s c m b l i nt lgl c n rt ( ) f r r ¡ l u c c : r l r l n s l i ¡ - r u r t t ( ) n . .\l\sc
_l
tftr in frrci¡lrcjrrten.rtionsurqcn. lrcrc is ¡ clr¡llcnqcrlss()ci¡lc(l with rhcsc(4)
c|Jti()ns\\'hcn \\'c vcrllr.¡rc into "lion rrnrlliqcr c()üntrv,"(I)cr.ltir)l-t in f()tcnti.rl
tllngcl rrrclsbcnclth thc SNIAS¡rndcl()scl() lhc lici¡l ncrvc br.rncncs, rvncrc
tlrc ¡rossiLrili¡, lullis r¡l dircct tllnr:r¡¡cto nclvc br¡nchcslnrl lossol .rninr.rrion
in lici.rl musclc.

()r'cr thc vc¡rs. nrJn\ srrrqc(r)sh¡r'c errrbr¡ccrl"clrrssic"rr¡pro.rchcs to rhlti

tlcctr¡nr',bcc¡uscfhcsclirn)ili:rf ()pcrrri()r)s
¡rc slrililr,htlir'\'.lr1l
.lnrl¡llorr l itlc.
¡)l)cnc\posufc ()t t:rcirlstIuctulcs.I Iorvcvcr,otrtconrcsh.rvcr.rricrlrvirlch,rlc
pcndine ()n thc v.lri.ltrlcclinic¡l prcscntlri()nol Prrticnts rrsrrcll ¡s thc .rbilitvof
tllc inciiviclullslrrltc{)nf() rclcirsc!1nclrc¡osiriorrclccpcrstrucfufcs.I-r()nrir hio.
rrrcchrnicrlpcr'\lc.livc. tli..liigon¡l rcctors ofthcsc chssie¡rroccrlurcs oftcn
liril to proclucctlrc tlcsircdrohrnrc rc(listrit)r¡1ion trc¡r'cen.lccpcr'.rnd supcrii
cixl Iilrcls-Fl-onrr l)llicnt's pcrcpe.tivc.rhc potcnti:rlconrplie¡tir¡rsofhlpc¡
tx)phic post¡uricL¡lnl sc.uring,tirci:rlfl.rtcning,end e pullcrl,Lrnn.rturll:rppcill'
 The MACS-Lift Shorr-Scar
FaccLift;Technicalánd StratccicConside¡árioN r85

ance detract ftom the aesthetic,natural outcome they expect and make these
claseicface-lift techniqueslessappealing.

The swcepdcformity, which resemblesthe NIKE "swoosh" tradcmark, is an all

too Íicqucnt sign ofa poor surgicaloutcomc from thcscproccdurcsand is a
major sourceofpatient dissatisñction.This problcm is attributablcto incom-
plete rclcascoffacial structuresand to the usc ofhorizontal tractionvcctors

We may be faultedfor failiug to fully examinethe limits of the procedureswe

perform and to accuratelyassess our ability to deliveroptimal rcjuvenation,
Morc thought must be devoted to thc goals of facial rcjuvcnation and the
most effcctiveway to achievethesesurgically,On closercxamination,thc classic
faceJift tcchniques that we have ¡clicd on fo¡ so long no longcr scrvc the
ncedsof many of our current patients,Therc is a dichotomy bctwccn thcse
dceplyinvasiveproceduresand paticnt requcstsand cxpectations. Today'spa-
tient wantsa natural-appearing, safc,and predictableoutcomc,but with con-
veniencc,rcducedmorbidity,and a shorterrecoverytime,

Many patientsturn to nonsurgicalcosmetict¡eatmentsto achievefacialreju-

venation without the sequelaeor ¡ecovery time associatedwith surgery.Thcre
is a definite role for complementaryproccdu¡esto enhancethe resultsofhcial
rejuvenationsurger¡ but we must understandthe limits ofwhat thesenonsur-
gical ucatmcnts cal accomplish. Therc is a current tendency to place enor-
mous valuc oo simple, often minimally effective ancillary procedurcs to en-
hance facial rejuvcnatron. However, the first emphasisshould be on perforrn-
r8ó Short Sd Fác.-üli Tcchniqu6

ing the firndamental, mandatory parts of thc operativeprocedu¡e to redistrib-

ute volume, tighten lax skin, and cnsurcprcciscrcdraping ofthe skin and deep
er layen back to their natural points offixation, Even excessiveuse ofnonsur
gical skin layer treatments (laserand radiofrcqucncy encrgy) will not compen
satefor inadequatesurgicaltechniqueto producefacialvolumeredistribution.

The current barbed-suturc facial rejuvcnation techniques have att¡acted con-

siderableatteotionbecausethey sccmto offer a classicrh¡idectomy in a min-
imally invasivefashion,Although tiesc barbed-sutureapproachesmay have
somevaluein facialrejuvenation,we may bc askingtoo much of a milor al1-
cillaryprocedurein lieu ofa more dcfinitiveprocedure.It is likely that the en-
tiusiasm fo¡ nonabsorbable ba¡bedsutureswill fadewhen surgeonsare faced
üth the removal of multiplc suture strandsin the future or have to deal with
the associatedcomplications,which includc possibledamageto thc salivary
gland duct, extrusio[, pain, and visiblc suture strands.Even in situationsin
which ba¡bed-sutureloopsare placedto simulatctighteningof deepcrlayers,
there arc no datathat demonst¡atctheir safctyand long-tcrm effcctiveness.

Alüough the classicface lift still has valuc in patients with pronounced face
and ncck laxity, it is not thc preferred option for many younger patiens or
those who want facial¡cjuvcnation without thc need for extensivcsurgical pro-
ceduresthat comc with associatcd morbidity and scarring.A varietyofdeeper,
more invasivcapproachcsfor facialrejuvcnation at the subpcriosteallevel havc
alsonot bcen widcly acccptedbecauseofconccrns about motor ncrve injury
swelling,and prolongedrecoverytime. Although surgeonsagrecthat thcrc is
a need to havc procedurestiat rejuvenatethe midfacc, few agrec about which
techniquesare most eflectiveand presentthe leastrisk.

In summary,wc must conti¡uc to think about the quality of our work, what
limits our rcsults, and ho\r wc can providc thc bcst rcsults for our patients.
Advancesin the qua.lityofoutcomcs in breastsurgeryrvereachievedwhen we
basedour decisionson tissuccha¡acteristics and implantdimensions.A simila¡
approachis needcdfor facialrejuvcnrtion,

Short-Scar Surgical Technique

Over the years,t}te short-scarapproachhasproveoto be an altemativeto the
classicform of facial rciuvenation.Shcrrcll Aston and Foad Nahai deserve
credit for t}¡ei¡¡olc in providinga forum for introducingand discussitgthese
short-scarface-liftproceduresin symposiaand publications.

Short-scar approachesin concept allow fo¡ the rcdraping of skin and reposr
tioning of decpcr layers back to points of fixation witiout excessivesurgical
 Th. MACS Lili Shon-Scirr-acet-ittr'ltch¡icil.nd SrratesicConsiderurio$ 187

dissectio¡.There is a sou¡rd¡natomic basisfbr how short-scartechniquesac-

complishvolumc rcdistribution.From a biomcchallicalengineeringperspcc-
tive, there is support for this approach'sability ro tighten the faceand ncck
without c{isintegratio¡r oithe f¡cial larrellac(skin, subcutaneous fat, SMAS,
and sub-SMASfat).

Daniel Bakeraccomplishcs fácialrejuvenationwith cxcisionof'SMAStissueto

vertically pull facial structures.He also incorporatcs¡ biaxial pull on thc
platysmafor necktightcling. (SeeChaptcró fbr morc detailedinformationon
this technique.)Dr. Bakerhas remai¡cd stcadfastin his criticism of dcepcr,
more invasiveapproaches.The it'tnovationsof Tonnard ¡nd Vcrpaclehave
yieldeda diffcrcDtapprorchthat uscssutureloopsto tighten and rcpositionall
drrcc zonesof the facc¡s dcscribcdby Mcndclson.The temporalisfasciais a
¡obust anchor point for thc platysmaand clrcck loops, preftrable to l,oré,s
fascia,asdescribedby l,abbé.The zygomrticpcr.iostcum, lateralto the cxtcr-
nal cantl¡alarca,is a suffcicnt anchorfbr thc ¡nidfhccloop. Othcr surgcons
ha\.enow rakc¡ thc cr>tceptsofllakcr, Tonnard,and Vcrpaclcasa fbu¡rdarion
ftrr¡.l.lition¡linnov¡tionin licirl rcjuvcnarion.

Bakcr,Tonrrardand Vcrprclc,and other short-sc¡radvocates arc Dot attcmpt-

i¡g to pcrfbrnr a "classic"lift through a short-scarapproach;their approachcs
rcly on r hairlürcincisio¡rin fio¡rt ofthe car. Mastcry olthe short-scarap-
proachrcquircsrhc usc of a varicty of "component" techniqucs,such as rhc
tcmporalbrow lift, lipo¡rlasty/platysmaplasry to lnrcrior ncckstructures,ano ¡
tirll rangcof oculoplasricproccdurcs.

UNDBRSTANDING THE MACS.LIFT EFFBCT

My i¡rtcrcstin thc MACS-lift stcmmcdfront 6rst rcadingTrrn¡ard and Ver
paclc'spnblications,thcn pcrfbrming a few cases,visitingand watchingthern
opcrate,lnd rcintirrcingmy undcrstandingin thc cadavcrlaboratory.With rhc
MACS-lifi, I ¡rm norv ablc to oft'er my patientsr tccl'rriquethat effecrivcry
tightcns skin tnd rcsrorcsthc dceperstructurcsto nrtural points of fixation
wirhorlt thc dow¡lsidcassoci¿rtcd
with morc invasivcprocedures.

Thc b¡sistbr thc chim of cfhcacyirnd satbryi¡ rhc MA(IS-lif'tshort-scarface

lift h¡s beenwcll cstal¡lishccl
by Torrnarcland Vcrpaclcin the yearsthat thcy
have been perlbrmiug tltc proccdurc,The techniqucsused in this operation
havea biomecha¡ric¡l¡nd ¡nlrc¡nticbirsisthxt fir cxccedsthe ,.microimbrica,
tions" that thc ¡L¡thorsclescril¡cdin thcir ñrst oublicationson rhe subiccr.I
prcfcrto look conceptullly at thiscfltct nsa "gatheringphcnomenon" ofrhe
SMAS layerof the fircc¡¡rd ¡tr¡chcd skin by the suturc loops.The volume is
rcdistributedwhe¡ thc suturcloopsrightentltc SMASiütd bring attachedsu
188 Shoft -Scd Face-Llft Tech¡iques

perficial fat a¡d skin along. The SMAS and skin can be reposirioned, or "gath-
ered," becauseof the deepersub-SMASfatty layer that allowsfor shearing
forcesin more superficiallayersto occurwiüout distortion ofdeeperlayers.

Anatomic and Biomechanical Foundations

Anatomic dissectionsby Mendelsonpoint to the needfor facialrejuvenation
proceduresto reapproximate deeperlayersbackto their points offixation. His
work describedthe anatomicpatternofligamentousfixation ofthe superflcial
fasciato the facialskeletonthat definesthe bounda¡iesthat compartmentalize
the faceinto severalregions,The conceptofpositioning the fixationat the lo-
cation of the original ligamentous fixation is quite difle¡ent from that i1 the
original SMAS surger¡ when the SMAS ¡eleasewas discontinuedbeforethe
midcheekligamentswere exposed.The SMASflxation in that situationcould
only be peripheraland was unde¡ tension.Becausethe support of eachana-
tomic region is attachedseparately to the facialskeletonat the locationofthe
origiral ligamentousfixation,tensionacrossthe enti¡eSMASflapis avoidec.

Mendelson'sth¡ee anatomicregiols of tlle face are all rejuvenatedby the

MACSJift technique.

The work ofl-abbé a¡d Ga¡dettohasalsocoltributed to the u¡d"r.tondirrg of

tensioningofdeeperlayersand the fact that the "SMAS" ofthe neckis actual-
ly the platysma fascia; these concepts aie important in understanding the
MACS-lift effect.
 Th. MACS Lili Short ScarFaceLift: Technic¡land StEtesicColsiderations r89

Labbé's anatomic dissectionsdemonstrate that a veltical plarysmapull urll

tightel al1dcortou¡' the l1cck.
190 Short-sc¡rlace-Lifi Tech¡iques

adposellssue
Superficial
s[4AS

Epidermi6

Plátysma
wLth"p alysmatascla"
Supéficiacerulcalfasca
Sl€nocEldoñásloid
ñuscls

Gardctto'sdissections showthat the SMASofthe faceis contiquousrvith thc

firsciaof the plarysma.

Articlcs by Mcudelson,Labbé, Gardetto, and Besinshavc urdcrscorcd the

cli¡rical¿urdbiomcchanicalvalueofshort-scarfacelifting asa viablcchoiccfor
facialrcjuveratiol. Thcir studiessuggestthat the laye!separatio[ofthc fácial
lamellaemay be uucccssaryto achievevolume redistril¡utio¡rard reapproxr-
mrtion ofaged facialstructuresbackto ¡raturalpointsoffrxation. Ifwe canat-
taiDthis rejuvenativeeffectwithout deeplyinvasiveapproachcs and usesutu¡e
fixation loops to accotrplishalmost the sameeffbct,wc have advancedour
ability to pcrforn facialrejtvenation.

Co¡sideratiouhasbccl given to the matter of how gravimetricaging of tl-re

ñce occurs,and biomechanicalengineerilg studieshave been conductedto
examinethc processwith a ñnite elementmodcling (FEM) approach.The
MACS-lift effect also dependson specificbiomechanicalengineeringprinci-
ples regardingsuture loops to shift an inelasticlayer of tissue(SMAS and
platysna)within the la¡nellaeofthe l'acea¡d neckwithout the necdto disinte-
gratethe normalanatomicattacl-rments that existbetweenthe laycrs.Thc con
cept ofa lamellarapproachto rejuvenationsurgeryis not revolutionary.It has
beel appliedto body contouringsurgeryby I-ockwoodand Avelar firr years.
 The MACs-Lili Short-scirFaccLift: TcchDical d Srfttceicconsidenrions r91.

Historicall¡ we haveuseda surgicalapproachthat delaminatcsthe lamellaeof

thc faceto rejuvenatcit. With thc MACS-Iift,rvearc ableto achicverejuvena-
tior by rcpositioningfat and deeperlaycrsby gatheringtissuesthat canslideas
a rcsultofthe undisturbedlayerofsub-SMASfat.

The MACS-Lift of Tomorrow

Additional*'ork is rcquiredto asccrtainthe volumeto be redistributedin e¡ch
of the th¡ee facialrcgions.Our tcchnicluesfirr MACS-lift facialrcjuvenation
arcstill impreciscand subjective,comparcdwith usingknorvnarnountsoften-
siodng firrcesor thc suturcloops(Newtons).Threc-dimensional imagingmust
bc consideredfbr assessing outcomcs of volumc repositioningprocedures
rather than the two-dimensiollxlcoÍltcxt thrt currentlycxists.Morc lesearch
nccdsto be donc to determinehorv to optimize the suturc máte¡ialuscd in
thc MACS-lift proceduresand to investigatewhetherbarbcd-suturcIoopsor
mcsh hru a practicrl role to phy. Applicationsof brorv lifting rvith meshhave
bccn rcported.

We srill lackan cflectivcproccdurefor midlaccrejuvcnationth¡t is lcssi¡rvasivc

thrn the subperiostcal approaches. Ultimatel¡ it may consistofcombining the
6ngcr-assisted midficc clev¡tion (FAME) dcscribcdby Aston or similartech-
nic¡ucsthat do not requireorbital region skin incisionswith the suture loop
susperrsion of thc exrcnded MACS-1ift.

The MACS-lift conceptmay also bc applicableto brow ptosis.Dcvclopmcnt

ofa ¡¡ethod fbr brow suspension without delar¡i¡ation oftl¡c fbrchcld is ¡¡r-
other topic that warrantsfürthcr investigatioD. Bctteroutcomcsfi"omfhcialrc-
juvcnationsurgcrywill occur aswe ccn relatcthe nccessary rnrount of forcc
(Ncwtons) to spccificfhcialzoncsto rcapprorimatcflt-containing laycrsback
to thcir ei¡rlierpoi¡¡tsofnxltioD iD the youthful face.

THE LEARNING CURVE FOR SHORT-SCAR

RITYTIDECTOMY
Successful intcgrationof a new surgicaltechniqucinto one's practicccan bc
challcnging.It iovolvesauditory and visuallcarling, bioskills,and strategics
fbr dcalingwith the normal cve¡ts that occur during surgery.It is a daunting
taskfbr surgicalcduc¡rtorsto transf-er knou4edgeand a skillssct to collcaguco,
especiallywhen the approachis counterintuitive.It appearscountcrintuitive
becausewc assurgeonsaretaught that wc needto takc so¡rcthingapartto re-
pair it. In this situation,u,eare usingbiomechanical engineeringto rcposition
tissuer,r,itl'rout
thc delar¡inrtion thrt *,e wcrc taught ;rssurgcons.
t92 Short sc.r lace l.if. Tcchniq{cs

Successful perfbrmanccofthe MACS-lifi sho¡t sca¡facclift demandstcch¡ical

cxcellenccfor the placementof suturc loops and thc rcsolution of tissuc
brrnchingdrat occursonce the suturc loopsare tightencd.The MACS-lift cf:
flct is equivalentto r gatheringphc¡omenonon the chcckand midfaceloops
to eflectvoluntc rcclistribution.

INDICATIONS AND CONTRAINDICATIONS

My crpcricnccrvith the MACSlift short-scarfacelift on a varietyof paticnts
lcadsmc to belicvethat in rnostcascs,thc short-scarapproachwill providcsr,rf:
licicnt acccssfor thc lccuratephccmcnt ofthe suturckxrpsand tighteningof
thc fice and ncck skin. Individualswith cxtremelylooseskin in the neck anc{
fircc¡¡av needextcnsion ofthc incisiorls
into thc ¡ct¡oauricul¡r
sulcus.Othc¡-
rvisc,thc surgeoncan rcvcrt back to cl¡ssicrhytidcctomyincisions,with thc
potc¡rtialdownsideof postauricularscar hypertrophyrnd diagonaltraction
vcctorson the skin.
'l'hc
bcst c¡ndid¡tcs firr this operationarc individualswith nrilclto mocleratc
f'ncill laxity who cirn bc managcclwith ¡ combincd a¡rproircl'r ofsurgicll op-
tiols that may incluclccomplcmcntaryproccdurcssuch as lipoplastyto thc
sub¡lcntal arca,autcrior platysmaplasty, oculoplasticsurgcry,brow lifting, fit
gr¡fts, nonanimalstatrilizcdhyaluronicacid(NASHA) ñllcrs,rnd neuroto\ins.
Additionall¡ a rcginrcnof mcdic:rlskin c¡rc rvill crrh¡lcc thc quality ofsurgl-
cal outcomcs.Pirticntswith morc scvercprcscntationsof fircialaging rnd lc-
tirlic d¡magcnri¡yrcquirccomplcmcntaryrLscoflascr rcsurfhcirlgaftcrsurgcry.

Co[trairdicatious arc si¡¡il¡r to thosc fbr other l¡cc-lift procedures:piticrlts

with ¡rrcdic¡lpxrblcms,unrcalisticcxpectctions,psychologicaldisordcrs,¡nd
lifé crises.Smokcrchave¡ l3-fbld incidcnccolskin nccrosiscomparcdrvith
nonsmokers.ln my clinic, I do not opcr¡te o¡¡ smokcrsarrdrequirea l2-wcck
pcrioclof absterrtionfiom all nicotinc-co¡rtaining proclucts.

ADVANTAGES OF MACS-LIFT SHORT-SCAR

FACE LIFT
'fhc
MACS-lift providcsa flexiblcapproachto fácialrcjuvenatiou,dclivcringa
nÍrturaloutcomewithout thc stigmaof inappropriatctcnsionvec¡ors,flattcn-
ing ofthe fhce,and thc tclltalesrveepclefbrmiryThis tcchniqr.recanalsorcpo-
sition midfacefirt lnd rddrcssr¡idfircc li,rxness.
Lipoplastyis efl'ecrivcin thc
rucckrcgior, thcrcbv ¡\'oiding ¡cck clisscctionthat scp¿ratcs
the skin fi'om its
a¡ratomic¿ttachmcntsto the underlying plawsmal fascia.
 llr!\lj\(\ljt(\!j,trr\!.r l:.rr I r l..lrl.rl.rj¡\rrrj!!r.(,,r,¡.r.rr¡,,. r93

I h c ¡ , t h c l l c n r . r r l i ¡ b l e , r r. r r t . r s c¡ , l r h c , \ l - \ ( . S l i l l r e c h ¡ i . ¡ L r jcs t l r . r ti r i s r c l s . r
r i l c . r r r d( l ( ) c \ r r ( ) 1l ) u f n l ) f i ( l q c \ :i 1 ¡ h c s r r l g c ¡ r llrr c l l e r c st h . r t h c o t s h c ¡ ¡ n n o r
o L r . r i n¡ s . r t i s t i ¡ t r i r r( ) r f . ( ) r r r c\ i l h l l ) c I I A ( S l i f i r c c h n i r ¡ L r cl l.r c f r 1 ) c c ( l L r f c
( ' i l nl ) c . ( ) r r \ c r f c ( tl o ¡ t r ' . r t l i t i ¡ I r ¡slt r L S
r , \ l \ S t l i s s c c t i r ¡rnr r t l r . rr - c t ¡ r ¡ U l i r L t l ¡tr, ,
e i r i o n . l l r c n ¡ . r t i r c l r ' .l h e t r 1 . \ ( l Sl i l i s L r r r r l lcr i o ¡ s ( . r r b e l e p r i n p l . r e e . r n dt l r c
s l i r ¡ r c t J r ' ¡ l ' r ' x1.1. ( ) r d j r r ql ( ) ¡ t r . r r l i t i o n . rt li c c l i t t . r ¡ p l o . r . h I l ¡ c r s r ¡ ¡ . r l l lrr . r r c
r r ( ¡ ( \ p ( f i e r r . c ( l c i l h c f ( ) f l ¡ r s e s i l ¡ l i ( ) n \ . h r r t ( ) J l e tl h ( r ) l . t s l , . r . l i L r p¡sr t l , t
s h { ) r l \ . . r f . r f I r o . r . h ' \ 1 1 e r ' 1 ' c l f i r l n r i nl h g c l l f \ r 1 0 \ l : \ ( S l i t i r . r s c s .r h c s r l

! , c o r r\ \ i l l i r . r i r.rr r ri r r . r ( . r s i n {( ( ) n r f )i l c \ e l \ \ l r t h i s t e ch r rr t ¡ uc . l l r r li r s f u ¡ n e e r .

Plott tt i rt.r1
Jbr a Strcctss-fir
I Orr tr:o¡uc
I ' o r l l r o s c r r l r o , r ' ( n ( \ \ l ( ) l l r i \ t ( . ! l l l r i ( l u c i.r i s ¡ c l r i r . r h l ct o h i c i r ¡ \ \ i t l r , r | t l . r
t r \ c l \ \ r f . r i q h t l i ) f \ \ . l f rl l, r i c l i l i o n ¡ | ¡ l t ( l r t \ i l l r n r i n i n ) . ttl , ) j r r { ) ( l i r . r t \(i q n \ ( ¡ l
. r ! . j r ! , .L ( ¡ ) \ . n e s \ i n t l r e r t . l , r l l ' r ( s e n l \ \ i l l t ( ) l l s i r - l ¡ i J j c , rlr¡rl r, r t r s n r l. ¡r . r r ( l i n q .
i s ¡ l s o L l c s i r ' . r b lSer.b r r r c r r r ¡ll: r t i l l ) f e \ c I t s h ¡ r U l i hl c t r c . r r c . r il i r l r l i ¡ r ' ¡ r l , r s r rI .I
l l r c \ ( e . r r l \ . , r s r \ . r r L \ t r n ( l ( ( l t r 1 . \ (S l t l l l l . l l r i t l ¡ t l , r . r l( ) l ) l i ( ) ¡l 1 )( ¡ s l f ( . l l

fi
\ /
\

)
tl

I h i s¡ r . r t i e rrrrti t l r nrik1/nroclcr'.rtc i . r .j ¡ 1 l . r rr r c s sn. r ¡ c r i , l cl l e er ¡ i 1 ¡ t , l ¡ ( ) l ) l r \ .¡ r ( l

. r t l c L ¡ r r .rrkr rcn r . r tl l r i ¡ l i r rsr sl o r l t l l " . | l r , , . . ' r . 1 . 1 r. . , , r l r ¡ \ l \ , . I r L .
t94 Shorr-ScdFace-LiftTechniques

COMPLEMENTARY PROCEDURES
Planning for a patient's facial rejuvenation usually involves additional comple-
mentary procedures, such as submental lipoplasty, anterior platysmaplasty,
lower blepharoplasty, ñllers(fat or NASHA fillers),and treatmentofthe brow
region. It is helpful to de6¡e the sequenceofproceduresto be usedfor each
patient.

oPBRATI!'E TECHNTQUE
Selectionof Anesthesia
From the perspective ofpatient safety,the MACS{ift canbe performedunder
monitored anestiesiacare,local anesthesia with minimal sedation,or general
anesthesia.Care should be taken to e[sure thar the patient is kept warm, to
addressdeepvein thrombosis(DVT) prophylaxis,and to preventeyedryness
if Eene¡alanesthesia
is used.

I begin the MACS-lift facial rejuvenation with lipoplasty and anterio¡ neck
work. I start by infiltratilg lipoplasty wetting solution with epinephrine
1:500,000into tie neck if lipoplastyor platysmatighteningis planned.The
wetting solution facilitatesdissectionand hemostasis.
 Thc ¡'l-{CS Lih Sho( Sc.trl'¡cc L¡lii Technical¡nd StrateeicConsidcriti(nN r95

Ultr¡sollic lipophsty is pcrfbrnrcdon firfty dcpositsin thc subme¡tirl¡rc¡. I

hrrvcfirLr¡cithc VASERultrasonicli¡roplostydcvice(SoundSurgicalTcchnolo-
¡¡ics,Louisvillc,CO)vcry cffcctivcin thc antcriorncckandjaw linc,bccirusc it
¡llou's preciseand accur¡tc¡cnrov¡loffit.

Next, I proceedto the short-i¡rcisionrh,vtidcctomvand flap elevatioÍr.C)ncc

this hasbeenaccomplished, I direct m¡,attcntionto thc ncckand checkloops
of thc MACSlift. Currcntlr,,I usc 0 PDS (clear)suturervith a robust ¡nchor
¡roint in the temporalisfáscia,approximrtclvI cm anteriorto the ear.
 196 S h o . rS . . r f r . . L i r r l . . h ¡ n l L , . \

'\
\\

'lhc
s u t u l cs u s p c n s i ( l)r1x14 . s. r l cu r r e l r o l ctt(l ) t h c l c r r r p ( ) f ¡ l li iss c i ¡ ¡ L r o v ct h c
/ ! q ( r D ¡ 1 i c¡ r c h . ( ) n c c l h c l l x ) P sh . r v ch c c r ¡ l . r c c , ¡l n t l I i c t l . I l i n i s hr r i t h t h c
r 1 1 i ( i f i rIc( xc ) l )( l 0 I ' l ) S ) l l r . i s . r r r c h { ' r ..(rl ¡ ¡ r ' o r i i n r . r t c1l.v5 c r ¡ l ¡ t c r ¡ l t o t h c
c \ l c r n . l l( . r n t l i . \¡lr c , r .I t i s i r ) r l ) ( n l . r rct .s l ) c . i . r l l irr - l h c l i r s tk x r I i n t l r c I L r t v s
nr¡, th.rl il lre |lrrcctlhckn| thc.¡r)qlcr)l-tl)cnr.rltlible\\ith ¡( Ic¡sl l\\() suturc
P ¡ s s c is¡ t ( ) t h c f i s c i ¡ . ' l l ) r t i l s t k x r p i s l i ! ¡ h r c n c (. lr ) ( l l h c k n { ) t si r r ct i c ( l it h c r r
l h c s c c ( ) n cd h c c kI x r ¡ r i s ¡ r . r r l cr r i t h ( n r al L ¡ t l i r rtqh c s L r n r r c . trlll c ¡ n c h ( ) rp ( ) i n t
to lrcl¡ nrirrinrizcllrc rnr()unt r¡f sutL¡tcrr¡rrtcr-i.¡l irt thc tcrrt¡ror'.tlis rcsion.tn(l
to ¡r'oid .r sccontl.lnch()rl)('inl. lrin¡llv.thc kn(,t {f rhc Itl)S sLrtulcis [rt¡ricd
¡¡rrl ¡ { 0 \'icnl s¡tLrc is ¡rl.rcttlin rllc (^cflvinq tissucl(' kcc¡ il (lc.plv
bLrricrl.

I-ivclitl¡rlocctlulcs.lrcl)cffi)fr¡c(l¡t tl)c cr)(i ol thc AIA(;S Iili bcc¡Lrscthcrc

nr.rvbc r siqnilie.rrrtrnr¡runt of sliirl r(rfuitnrcrrt lticf rhc \utLrfcIxr¡rs lr.rru
bccn pl.rccil.

Managing Burrching'Iissuc
I thcn lircrrson rcsohing .rnl lcsitlu¡l hunelrirg ol S,\4AS.rrri shin lissucs.Thc
sLrtrrrc I(x4)susc(lirr thc prrrccdLrlc rrill hlrc r g,rthcringcflcct (nl t¡cixl risslrcs
rs lhc\'.rrc brought [)¡cli ul) l() llrcif nornrll ¡lrints ()l iLltirchnrcnt. Alth()Lrgh
l h c . r n r ( ) L r (n)tl b u n c h i n gt h ¡ t ( ) c c u r as , r l rh c s o n r c r r h ¡Jt l . r r n r i ntq( ) ¡ n i n c \ p c
ricnccdsLrr!:,c()o, this tissuccirr l)c niar:llsrr(nrlhc(l()ut.

-r€ rI-¡-
 The MACS I-ift Shoú ScarFaccLili: Tech¡icala¡d SrratesicCons €ntnm t97

Bunchilg af'tcrthc slrtureloo¡rs:rrc tightcncd is normal. Depcndingon thc

amount oftissuc i¡rvclvcd,this may rcquire trimnring u,ith the scissols(lop)
¡¡c1sutL¡reinsettilrg(bottow)to fltten tl'reridgesusing4-0 Vicryl. Smallskin
climplestLnclerncath thc fllp will rcquirctlre useofthc scissorsto releasethe¡n.
However,:rnattempt should first [¡e m¿rde
to flattcn thc bunching rvith suturc
bclbrc usinethe scissors.
193 S l ¡ )r \ . . u l . r f . t r r r l . . h r i r t L r e .

Arrirnging thc Skin Flirp and Estltrlishing Hemostirsis

S l i i r rc r c c s si n t h c , \ 1 , \ ( . Sl i l l i s | c s o l r c t rl v i t h . r| c I t i c . r .l r ¡ 1 r r o . r cIltr .i s i n r ¡ o r
t ¡ n t r o t ¡ l i c t h c r i n r ct o . r r r r r r r j tch c r k i n l l . r | . r l i c rl o r l i i n t l r cd e c ¡ c rJ . r l c rlsr . r s
b c c n c t r n r ¡ l c t c itlo c n s L r rscr r r r n r c t r i ct¡cl r s i o r r c. l i r r r i n ¡ t cb u n e l r i n g..r r d c s
t ¡ h l i s hh c r ¡ o s t , r s i s .

/{ $t.

V c n ( f l r r c l r )'
'I
l r c c l l i ( . r . \ ( ) l l h c s l \ ( ) r l\ r . r f \ c f l i ( ¡ l . r ¡ r ¡ r r r r . rN r lirl l h c c o r l l cc r i t l e r r ti l t h c s r L r
c c o n ¡ L r l l st h e s h i r r1 l , r ¡irr r t l r c l l o n g t l r o l i z o n t . r l rL l i l c r ¡ i ¡ , n .l l r i s Irr ¡r i , ,r ,rr t .r I
t r . \ ( l i ( ) r () ) n t l r t s h i r rf l . r ¡ r r i l ) r c r ¡ u i l e . r f c t f r ' . r r f i c u l , rifn t i s i o r rr . r t l r c rt l r . r r t h c
\ r f l r ( . r l l r , l a t i ( ) r ( ) n t h c 1 l . r ¡ t l r . r t r c s o l r c se r t s r s l i i n r r i r l r o L r rt l r l n c c . l l i , r
I c l r ( ) . r r f i (L r l . r(rl r s s c ci (l ) r r .

S l i i r i r r t s e c t r r it o ¡ r o i L l s h i n t c r ¡ r i o r r ¡ ¡ t h e w o r n t l l h i s i s c r u t i . r l t ¡ r o b t . r i r
l i r o r . r t r l c¡ r o s t o ¡ r c r . r t isr c¡ . r . S i i i n r c s r r l i ( ) r )i r r t l r r r l c \ . t t i , l s l i r r n r r . r . l ct o n r r
f { ) r l h c l ) r r . l L r f i . u l . lrrc q i o r ¡ , riln c i s i o r rt l r . r t\ ( ) n r ) r . r ( l c . rltl r c s t r f l ( ) 11 h . r ¡
F o l t r r n . r t , : l rb, t e . r L r socl k r . . r l. r n . r t ( ) n r "i (. I n . l r o r ¡ , , i n t s " r l r t s i . l c b u r r . r n . l I r . r
g ¡ l ¡ 1 c . r s( l ( ) r ( ) l r r r ( n c . r | ) ¡ f ¡ t j i l i t . r t cl h c ( l ( ) s L r r lc) r o ( c s s .\ l ¡ c l i o l l i c i . r l l l r ¡
t c n s i r ¡ ni s l c ¡ l i v i m p o r ' t . r nitr r t h r . l ( ) \ r f c .

I i t h c \ r r r g c ( ) nl i n r l st l r . r tt l ¡ e r c i s t r ¡ r n r L r c hI x r s c s l i r r r c r r r . r i n i n , ] . r r r ol rrrtr
. r L l r L rst l i i n L ) L L n c h i ni ,nr t l r c p r c . r L r r - i c L r l . r r . rirt' ci s. r .P c r r r i s s i b l ct o i l s c t t l l c
k ¡ ¡ r s c n c sbs c h i r J t h e t . r r . I h i s r l r . u r r u \ c r. { ) ¡ r c s l i t h t l ¡ c r i l r n s i . i c o l n ¡ r , , .
d i s s e c t i o n¡ n 1 1s l i i r rr h i f r i n g r o l i n . r l i / r t h c r l ( ' s u f c .I l ' s r ¡ r c L ¡ u r e h i n gi s l c l i h c
h i n d d r r l i n ! r¡ l ¡ r s u l c .i t s h < ¡ L r l dr t l o c ¡ t c i l b e h r n c rl l r c c ¡ f l ( ) h c .n ( ) l i r r l i ( r n r
 The MACS Lift Short'ScarF¡ceLift: Te.hnicd and Strátec'cConsideratio¡s r99

Skin Closure
Tonnardand Verpaeleuscsmalldrainsplacedin the arcaofthe carlobe.I pre-
fer to useñbrin glue (Tissecl;BaxtcrHealthcare,Deerfield,IL) that is diluted
to 5 units/ml insteadofd¡ains.I find that fibrin glue alsohasthe advantageof
diminishingecchymosis in thc postoperativeperiod.Fibrin glue can produce
hcalingproblemsifexcessivcamountsare sprayedin thc wound. In my expc-
dence.a I ml vial ofTisseclis adeouatefo¡ both sidesofa MACS-Iift.

As discussed prcviously,skin closurcis performcdundcr no tension.I use5-0

Monocryl suturcsin the subde¡r¡alarcato hold the wound and 5-0 and ó-0
Prolcncin the skirr (horizontalmattresssutures),A few 5-0 rapid-absorbing
plain gut suturescanalsobe used.Careshouldbe takento rcmoveall silk tem-
porary sutur€sthat were usedin tic planningstageof the closure,Minim¡l
skin rippling will resolveir the postoperativeperiod.

Eyelid and Brow-Lift Procedures

After the MACSJift is completed,thc eyelidprocedurescan be initiated.Bc-
causea significantamount of skin hasbeenrccruitedinto thc orbit with thc
midfaccloop, a lower eyelidblepharoplasty will be neccssary
in many cases.
Brow procedures,whether a late¡altemporallift or an endoscopicbrow lift,
can be performedin coniunctionwith the MACS-Iift.
200 short-ft¡r Face Lift Tech'¡iques

POSTOPERATTVECARE
A simple dressingafterward is suficient, I prcfer silicone-backedfoam tJrat rs
used for lipoplasty proceduresin the antcrior neck to control skin wrinkling af-
ter neck lipoplasty and anterior platysmawork. Foam is also helpfirl after en-
doscopic brow lift to cont¡ol forehead swelling, Patients generally recover
more rapidly from a MACSJift than from a classicrh¡idectomy. In most cas-
es,swelüngresolvesin l0 to 14 daysand the feelingoftightnessin 4 v¡eeks.

CASE EXAMILES
Aeohetic Annlysis
This S9-year-oldwoman requestedrejuvenationof her face, lower eyelids,
neck, and lips. She desiredsurgicalimprovementof her neck bandsbut did
not want an open procedureto tightcn hcr neck.Shewashealthyand did not
smoke.The patientwassatisñcdwith prior useof NASIIA flllersin the lip rc-
gionsand neurotoxinin the glabellaand crow's-feetregions.

S*rgictl Phn
The trcatmcntconsistcdof:
. An extendedMACS-lift
. VASERüpoplastyto submcntala¡ea
. A lowe¡ blcpha¡oplasg
. I ml Restyla¡cto lip lincs andnasolabialfoldsfor maintenanccof
existinecor¡cction

Portoperñtirt e Re sttlts
Postoperative resultsat I yearshow improvementin the faciallaxity and vol-
ume redistributionof tissuein the cheeksand midf'acc.The neck contour is
improved,althoughsomeminor bandingis still preselt. This is not ofconcern
to the patient.Laxity offacial st¡uctuleshasbeencorrectedwidr tl1eextended
MACSlift and with the usc ofNASHA fillersin the lips and nasolabi¡la¡ca.
llr( ¡l \( \ j ii \lr(rr S!¡rlj.r!.litf l..tri..rl.rrt\r'.r(.,¡i.(Lir\¡r.rr¡¡¡ 20t
202 Shorr-ScdFace-LlliTech¡iqúcs

Aesthetic Analysis
This 54-year-oldwoman requestedrejuvenationof her face, lower eyelids,
neck,and lips.Shewasinterestedin v¡hatcould be done surgicallyto improve
he¡ neckbands.Shewashealthyand did not smoke.Shehad a history ofa suc-
cessfulLASII( procedu¡e for the t¡eatment of myopia 3 yearsearlier Her tear
film breakupwas normal.

Surgical Plnn
The treatmentconsistedof:
. An extended MACS-lift
. Á¡lterio! platysmaplasrywith VASERlipoplasty
. A lower blepharoplasty
. 2 ml Restylaneto lip linesandnasolabialfolds

PostoperativeReswlts
Improvementin the ñcial laxnesswith volume ¡edistributionof tissuein the
cheeksand midfaceis seenI yearpostoperatively. The neck cogtour hasalso
been improved through the combination of VASER lipoplasty, anterior
platysmaplasty, and the verticalpull from the MACSlift suture.Additionally,
the midfacehas beencorrectedwith the extendedMACS-lift and the use of
NASHA fillersin the nasolabialarea.The preauricularscarsdemonstrateex-
cellet.lthealins.
 I..lr.idlr¡(1 lnr((!ji. ( .¡n¡. 1roib 203

]F
! ,¿ill
(*'

'rF¡r
204 Shorr Sc¡r FaceLift Techniqucs

Su't'gical Peat'ls
For one's initial cases,choosepatientswho pose fewer problemsand
would likelv have an excellentoutcome with a classicfacelift.
Dcvelop a plan that encompasses both surgicalrejuvenationthrough
tighteningoffacial and neckst¡ucturesand volumeredist¡ibutionof fat
aswell ascomplementarynonsurgicalproceduressuch as NASHA fill-
e¡s-neurotoxins.and medicalskin care.
Whenplacingthe firstsutureloop to tighten the neck,makecertainthat
the needlehas a good bite of platysna fasciabelow the anglc of the
nandible.A lightedretractoris usefulto helpveri$' good fixationofthe
platysma.
When placing the secondloop of suture to lift the cheek,do not be
temptedto makeit smallerdranplannedpreoperatively. The largcrloop
allowsfor maximaltissuegatheringinsteadof producinga bothcrsome
wad of cheektissue.
Ifthe sutureloopsdo not look right or the amountofgatbering or cor-
rection is inadequatc,cut the sutures)removethe loops,and start over.
Excellentcorrectionoflaxiry is needed,rvithsecurereattachmentoftis-
suebackto its originalpoint of adherence,If correctionis suboptirnal,
takethe time to achieveoptimalcorrection.
Finessein controllingbunchingand skindimpling is essential to achiev-
ing a smooth contour. Devote the necessary time to smooth the co¡-
tours. It can be helpful to drapethe skin flap over the lifted tissueald
look for visibleor palpablecontour irregularities.
Skir,wrinkling in the inferio¡ ear will generallyirtprove with timc. It is
pcrmissibleto go behind the eaf slightly to inset skin, if neccssar¡to
control significantwrinkling, just asyou would if there were a dog-ear
at the end ofa wou[d closure.
Excessive dissectionshould be avoidedin the retroauricularareaor on
the surfaceofthe sternocleidomastoid muscle.Both ofthese arenatural
areasofadhe¡encebetweenskin and deeperstructuresand representin-
fcrior anchorpointsto the verticallift with the sutureloops.
Considc¡the useofthe silicone-co¿ted foam drat is usedin lipoplastyas
a dressingto help control swellingi¡ the cheeksaod anteriorneck,es
peciallyafterlipoplastyor oper anteriorplatysmaplasty.
Widenessin the area of the sternocleidomastoid muscle,apparently
causedby tensionfrom the first vc¡ticalloop, resolvesin a few daysafter
sutgetv
 The MA(IS-Lift Shor!'ScirFice Liftr Tcchnic¿l¡nd SthteeicConsideratióls 205

BIBLIOGRA}HY
AvelarJ.Regional
clistribution
xndbehavior
ofthesubcutirneous
tissue
conccnrirg
selec
tior andindic.rtion for liposuction. AcsrhcticPl¡stSurgl3:155-ló5, 1989.
Balcr DC- Decp disscctionrhytidectomv:A pleafor c¡ut¡on.lllrst ReconstrSurg93:
t498 t499 , t994 .
BakcrDC. Facclifi rvith sLrbnr¡nclibIl¡r glancland digastricmusclcresection:lhdical
ncckrhytidectonly. AesthcricSurgJ 26:lt5-92,2006.
BakerDC. IáteralSMAsectorlly. I'lastRecoustrSu¡g100:509-513,I997.
BesinsT.'t-he "R.4.R.L.."techniquc(rcycrscand repos¡t¡oning cfl¡ct): The rcn¡issance
of the agingficc ¡nd ncckIreviervl. Acsthctic Pl¡stSurg28:127-142, 2004-Epnb
2004,Ang 3,
GardcttoA, D¡trcrnigJ, Rrincr C, et al. Docsa supcrficialmusculo¡poncurotic systcn)
c\ist in the ficc and necb An anato,¡ic¡lstudl'by thc tissucpl¡st¡mt¡o,rtcchn¡quc.
P¡¡stRcconstrSurgI I I:664-672,2003.
Labb¿l), !ranco l\C, NicolasJ. Itlrt),snrá suspcllsion Llndplrtysm¡phstyduringncckIift:
An¡to¡11ic¡l stud.vand¡nalysis of30 cascs. Plastll,(constrSurgI 171200l-2oo7,2006.
I-ock\(xxl f, BrKmdi lL-I-o$'crbod! lifi s'ith supcrfici¡lf¡scirlsystcmsuspcDskm. Plast
Rcconstr Srrg92:I123 I125, 1993.
Mrt¡r¡sso Sl,, (l¡rrudrcrsJD, Icwcll ML; Rcstylanc (inrscnsusCroup. Conscusus rcc-
onrnrcndatiorls fir¡ soh-rissuclug'ncnrirrkn with non¡l¡1i¡'n¡l st¡bilizcd h.v¡luronic
¡cid (ltsq'l¡nc). I'lastlLcon$trSurg I l7( 3 Suppl):35-34S, 200ó.
(),
Mazz¡ !1,P¡pcs l\¡bin MB, ct al. Nonlinc¡rrcl¡st¡c-\'i$copl¡stic constitr¡tivc cqlations
fbr rgingf¡cirl rissucs. lli(nncch ModclMcch¡nobiol 4:178I89, 2005.Bpub2005,
Auli I2.
McndclsonBC. Sru¡¡crvof thc supcrfici¡l¡rrus(ulo¡poncurodc s1'stcm: I'rinciplcsof rc-
lcrsc, vcctoru, utl fixati(n.PlisilkconstrSurg107:1545 1552,2001.
MossCJ, Mcndcls(nlB,l'xykn GL Surgicil:uatomyof$c Iiganrcrrtous attnchDrc|ltsiu
drctcmplcandpcriorbitrlrcgions. Pl:rsr
Recoostr Surg105:1475-1490, 2000.
Mrt¡f M. Mcsh lili: A ncw pfoccdurcfin l(ng'lasti¡rgrcsulrsir br(^v ¡ifi rurgcrr. Pl¡st
I{cconstr SurliI ló:1490 1499,2005.
RccsTD, Livc¡cr¡DM, Guv (1t..The cft¡ct ofcig¡rct¡c snrokingon skin flrp survivalnr
thc licc lif! p.rricnt.I'l¡stlUconstr Sufg73:91I915, 1984.
Ruff G. Tcchn¡quc¡nd Lrscs fi)r ¡Lrsorb¡lblc
bartrcdsun¡rcs. AcsdrcticSrrgl 261620-620,
200ó.
Tcbbcttst, Achicvirlg¡ zcro pcrccntrcoflcrxtionr¡tc irt 3 yearsirr:r 50-co|rsccotivc-c¡sc
illrgmc¡1t¡tiornr¡mmirplirsty pfcn)rrkct ¡pprovil srudy.Plisr llccooslr SurB llEi
| 153-t457, 2006.
Tcbb{¡s J, AdanrsW FiYccritic; clccisi()ns ¡rrbrcast¡ugmcrrr¡d(nrlrsingfivc nrc¡surc
n)cntsin 5 nrinutesrThc high ñvc dccisionsupportp¡occss.Pl¡st RcconstrSurg
I I8(7 Suppl):35S-45S, 200ó.
To¡)nrrdI'L, VcrpaclcAM. Thc MACS't,ifi Short'Scarlulytidcckrnv.St L(nrisrQuxlir\'
Mcdic¡l Putrlishing, 2004.
q
Tonnrird Vcrp¡lcleA, MonstrcrS, ct rrl.Minimalircccss crani¡lsuspcnsion lift: A moo'
ficdS'Iift.Pl¡stReconstr Surg109r2074-208ó, 2002.
Wi¡rklcrE, Goldr¡rO, RegcvB, ct al. Stcnscnduct rupn¡¡e(si¿bcelc)urd orhcrcompli
cxt¡onsofthc Aptosthrc¡d tcchniquc.I'lxstReconstrSurgI l8:1468 1171,2006.
Short-ScarFaceLift
Evolwtion nnd.Appli coti ons
D.rnielC. Baker
208 Short-Scarlace-Lift Tcchniques

RHYTIDBCTOMY IN THB TWENTIETH CBNTURY

Rhytidectomyis a procedurethat continuesto evolveassurgeonsseekto offer
patientsnatural rejuvenationwith reducedmorbidity. Over the yearsI have
witnessedan evolutionoftechniquesrangingfrom basicskin lifts to superficial
musculoaponeurotic system(SMAS)proceduresto evenmore complexdeep-
DlaneoDentions.

F¡iedlandhas diüded the history of rh¡idectomy in the twentieth century

into four generations,beginningwith simpleskin lifts and ending with deep
dissection,more radicaltechniques.

First Generation: Up to World War II

. Skin lift only
. Subcutaneous dissection,variableundermidng

SecondGeneration: 1950s to 1975

. Subcutaneous
dissection,superficialplication,skin lift

In 19ó8, lohn Conley bestsrmmarizedthe plication techniquein his book,

Fece'LiftOperetion,asfollows:
1. Plicationis done in long thin faceswith a paucityofsubcutaneoustis-
sue,
2. The subcutaneous tissuei¡ the cheekis plicatedinferior to the zygo-
matlc arch.
3. Imbricatethe centralpart in hollow sunkencheeksto obtain firllness.

However,Reesemphasized that the effectivenessofplication wasa greatpoint

ofcontroversyarnongplasticsurgeons.Tipton's paperin 1974,demonstrating
no diffe¡encebetweenthe plicatedand nonplicatedside,convincedmanyplas-
tic surgeonsto abandonplicationtechniquesin facelifting. When SMAS dis-
sectionbecamepopularafter the work of Mitz afld Peyroniewaspublishedin
I97ó, it becameroutine to include a dissectionof the lateralSMAS direcdy
over\ing the parotid gland.This led to the ¡ext gene¡ation.

Third Generation: I970s to L980s

. Subcutaneousdissection,more extensivedeñtting
. SMAS and olawsmaflaos
 Short-ScárFaccUft: Evolution ánd Applications

My first expcriencewitlt rhytidectomy wasduring my plastic surgery residency

in the late 1970s. At that time, a combination of cxtensive defatting of the
neck with complete platysmamuscletransaction,plicating medial borders, and
pulling laterally was p¡esented as the only way to get the best result. Yea¡sof
patient complaints, compücations,and overoperatcdnecks occurred before I
abandonedtllis approach.

I performed SMAS dissectionin the late 1970s and continued to do so into

the mid-I980s, but overall I was disappointcdwith the effectsofa sirnple ele-
vation and tightening of the late¡al supcrñcial fascia.Spccifically,I saw litde
diffc¡ence in ovc¡all facial contour, regardlessof whethe¡ I had performed a
late¡alSMAS dissection.

As I gained more expericncewith SMAS dissection,it becameobvious that for

the supcrficial fasciato producc any effective change in facial contour, it was
neccssaryto elcvatetlte mobile SMAS anterior to the parotid gland, Thc prob-
lcm üth this mo¡e extensiveSMAS disection is that facial nervc b¡a¡ches arc
placed in grcatcr jcopardy. I also notcd that thc $upcrficialfasciatends to thi¡
out asit is dissectcdmore antcriorl¡ making it easicrfor thc SMAS to tear. All
too oftcn, I would note thinning and tcars aftcr clcvating a SMAS flap. Any
signiflcanttensionplacedon the SMASflapin suturingwould ¡esultin furthcr
tca¡s. Fo¡ üis rcason, I concludcd that an extensiveSMAS dissectionwas not
warranted in most patients and offercd litde long-tcrm bencfit compared with
SMAS plication.

Bccauscof disappointmcnt with longcviry and improvcmcnt of thc midfacc

and nasolabialfolds, the tcchniques bccamemorc invasivelcading to the ncxt
gcncranon.

Fourth Generation: 1990s

. Compositerh''tidcctomy
. Subpcriosteallifts
r Subplatysmasurgery

During the 1990s, prescntationson dccp dissection rhltidcctomics, subpen-

ostcallifts, and cndoscopicapproachcs attestedto the splendorofcreativesu!-
gery.The contributionoftheseapproaches is alreadyevident:an increased and
clearcr knowlcdgc offacial anatom¡ muscle function, and human expression,
Some aspccs ofthesc techniqueshave bcen incorporated by many plastic sur-
geons.What rcmains to be answeredis: (I) What arc the indications fo¡ thcse
deeptechniquesf(2) How greatarethe risksand complicationsf(3) Most im-
portant, do the bcnefits of tl¡ese techniques outwcigh their risks significandy
enough to justifi using them routinclyf
2LO Short ScarF¡cc Lift lcchni{tues

Interal SMASecmmy
In 1992, I discovcrcdthe beneñtsofthe lateralSMASectomyasan altcrnative
to formallyelevatingthe superficialfascia.With this approach,a porrion ofrhe
SMAS is removcd in the region dircctly overlyingthe a¡terioi edgc ol the
parotid gland. Excisionofthe supcrficialfasciain this region secu¡esthe mo-
bile ante¡iorSMAS ro rhe lixed portion of the superficialfasciaoverlyingthe
parotid.The SMAScctomyis pcrfbrmedin a directionparallelto the nasolabr_
al fold to ensurethat the vecrorsofelevation after SMAS closurewill lic pcr-
pendicularto thc nasolabialfold, therebyproducingimprovcmentin this ibld
aswell asin thc iowl ¡nd ialvlinc.

Identicnl Twin Swdy

In 1995, ¡ live surgicalteachingcourscwashcld in San Franciscou,ith fb¡¡r
diflerent surgeons(llaker, Ham¡¡, Owslc¡ and R¡mircz) operatingon two
sctsofidentical twins,with cacltsurgconusinga diffcrcnt t..hniqu". F.rllo"_
up at I, ó, a¡d l0 ycarsdcmonstratcdno significantditl¡rcnce in resulrst¡.¡q
longcviry.

Rcsurgenceof Plication Techniqt4¿s

In the mid-1990s,therewcrc ¡ numbcrofface-lift articlcswith larqescrics¡c_
porting on the bencfitsand successof SMAS plicrtion only (Friidland 750
cascs,Pitanguy8000 cases, and Robbins4000 cascs). Thcscexpericncc<l sur_
gconsfelt thcrewasllo diflerc¡cc in the resuLrs
wirh n.torcinvasivetcchniqucs.

WbyDid Plication Fall Oat of Fawr With Man¡t

Plnstic S*rgeons?
Suturcswcretoo superñcial (subcutaneous
fat) out offearoffacial
nervcuIury,
The vcctorswere ilcorrect.
Thesutureswerctoo frne.
The suturcsweretoo few.

Although the dcbate continuesabout which rhytidcctomytechniqucyields

the bestresults,¡ro singletechniqueis best.Most techniquesare.,ariations.r.,
a basictheme.What hasclearlyevolvcdin the rwenty,firstcclrury is thc trcno
to lessinvasiveproccdureswith low morbidity,short recovery,and minimal
scars.That most parientsare happy tvith the simplertechniquesis obvious.
 Short-Scd FáceLift: Evolution md Applications 2ll

The fact that the deeply invasive,more radical techniquesdo not produce ap-
preciably better results hasmotivated most plastic surgeonsaround the wo¡ld
to rely on the less-complicatedstandardtechniques.

Each surgeon must adopt a technique that serveshis or her patients well and
ideallyis safe,consistert,and applicableto a varietyof anatomicproblems.

RFTYTIDECTOMY IN THE TWENTY-FIRST CBNTURY

In the twenty-ñrst century, ¡hytidecromy hasadvancedto the ner.t generation
with minimaJly invasiveshorr-scar technjques.

Fifth Generation
. Subcutaneous undermining,SMAStreatment(plication,SMAsectomy)
¡ Sho¡t-scar,S-Iift,MACS-lift
. Suspension sutures
. Fat grafting and fillers

Sbort- Scñ r Rhlü d¿ctom !

The short-scarrhltidectomywasdevelopedott ofthe demandsofyounger fe-
malepatients(mostlyin their forties)who soughtfacialrejuvenationbut were
adamandyopposedto any scarring behind the ears.Thesepatieflts objected to
the postedor hairünedistortion, hlpertrophic scars,and hypopigmentation
that they often observedin tieir f¡iends o¡ mothers who had undergone face
lifts. They were embarrassedto wear tieir hair up or in a ponl.tail with such
scarsvisible.

I performed my first short-scarrhltidectomy in 1990. The paricnt was 4l

yearsold and had submentaland submandibularfat and earlyjowls but good
cerücal skin elasticity.I perficrmed liposuction ofthe neck and jowls with wide
subcutaneousskin undermiuing in the face,detachingtlre malar and massetero-
cutaneousligaments.A pure skin lift was done with no retroau¡icula¡sca¡s.
The result was superb, and I incorporated tiis procedure for all my younger
patientswith simila¡anatomies.

In 1992 I beganto add the latemlSMAsectomytechniqueto the faceJiftop-

eration for young women in thei¡ forties. However, I noticed that ve¡tical ele-
vation ofthe face also affectst1lecervicalskin to some degree;la-xcervical skin
was also tightened becausethe soft tissuesof the face and neck a¡e linted
anatomically. Between1990 and 1998, 209 young femalepatientsu¡de¡went
this operation without ¡et¡oau¡icula¡ sca¡s.
2t2 Shon S.d Faceüft Techni¡luca

As I becamemo¡e confident about thc ¡csuls and the opcration, I began to

perform it in older patients with more progressivejowling and cervical laxity.
In these patients, it was necessaryto undermine further in tlle neck and over
tie ste¡nomastoid and submandibular regions. This exposed the platysma
muscle in tie neck, which enablcd resection of thc posterior muscle continu-
ous with the SMAScctomy.By resccting platysmaover the ail of the parotid
glald and antcrior bordcr of thc stcrnocleidomastoid, thc facial ne¡ves wcre
protected and the platysmacould be tightened with a lateral vector.

Between1999 and 2005, I pcrformed 173ó sho¡t-sca¡rh¡idectomies üth

late¡alSMASectomyor plication.Patientsrangcdin age from +0 to 74 years,
all with a varietyof facialagingsignsand ncck deficrmities.I now believethat
the techniquehasprogressedto the point whereI cansaythat it is reliable,as
safeasthe other procedures,and should be reproduciblefor most plasticsur-
geons.In gene¡al,it produccsconsistentresultsin properlyselectedpatients.

The primary advantagcof short-scar rhytidcctomy is that it allows patients

who wear their hair pulled up or back to do so, Any retloauricular scarring or
disruptionofthe posteriorhairlincmakesthcsepaticnrsunhappy.In addition,
thc opcration involves lessdisscctionand is lessinvasive;pr€sumablythis caus-
es lesspain and resultsin a sho¡ter healing timc. In patientswho dcvclop
hematomas,evacuationis easicrüth lcss morbidity.

Thcrc a¡c disadvantagesaswell. This tcchliquc is not suitablc for all paúents,
cspcciallythose with scvcrcccrvical skin laxity. Bccausca signiñcant ve¡tical üft
is required, strict attention must bc paid to minimizing tempora.lhai¡line shifts.
I¡ certainpatientsan antcriorhairlineincisionmust bc used.Fitting dog-ears
into the temporaland earlobearcascan bc a challcnge,and theseareastakc
more time to softel and flattcn.Exposurcofthe neckwith the short-scartech-
nique is limited, makingthe opc¡ationtech0icallymorc diffrcult.

I do not usc this techniquein cverypatielt. Patientswith severece¡vicofacial

Iaxity and lossof elasticitybenefitmore from classicrhltidectomy operations
with letloauricular scars.
 Sho.r-Scd Fae I-ift: Evolution dd Appli<¡tions zt3

TYPBS OF CANDIDAIES
Basedon my surgicalexperiencewith this procedure,I haveclassifiedcandi-
datesinto the following four types.

Tlpe I: The Ideal Candidate (Early to Late Forties)

Ealylowls
gubmontallat

Sllghtctrvlcal lsrlty

Cherecter¡3tlca Surglc¡lPlán
A96 6arly!o lato foñl€e Suctlon.a$bt€d lipopla8ty
lnack)
Aglngpdmarlly lacla S[,lASeclorny
Earlylowllng onlyln a lhlntac€
Pllcatlon
Sllghtc6rvlc6lBklnlaxlty ohlnlmplanr
ll Indlcatsd
May havéoubmsntalfat

Goodcarvlcalsldnelá3ücty

Ideal candidatesfor a short-scar rhytidectomy are usually in their carly to latc

fortics, with aging primarily in üe frcc. Although they may have slight ccrvi-
cal laxity, skin elasticity is still good. They have early jowling and often sub-
mental and sr¡bmandibularfat. Microgenia may also be present.

These patients are effectively t¡eated with closed lipoplasty of the neck and
jowls,wide subcutaneous skinundermining,and lateralSMASectomyor pl.ica-
tion with or without platysmaresection.No retroau¡icularincisionis necessary
to improvethe neckand frce. Ifindicated, a chin implant enhancesthe result.
 2t4 short-Sca¡F&c-Lift Tcchniques

Tlpe II: The Good Candidate (Late Forties to Late Fifties)

subm€nralfai
Mod€lal€o€ lcallaxily

Characlerlallca

SlvlAs€otomy
ilod€fale carvlcalakln l6¡ity Pl|callon
onlyIna thlntac€
submontal/submand¡bular lar chln ¡mplanr
í Indlcáigd

Noacllv6plalysma
bandg

Good candidatcsare usually in thei¡ late forties to late fiftics with modcrate
jowling and cervicalskin laxity.Submandibularand submentalfat is usually
present,and thcy may havemicrogenia, Mcdial platysmabandsare not prescnt
on normal animation. (I do not evaluatcthe platysmaon forced a¡rimation or
on the basisofstatic photographs;often what mayappearto be sig¡ificantpla-
tysmabandsrepresents laxity onl¡ which canbe correctedwith a lateralpul-.,

Closed lipoplasty of the neck and jowls along üth lateral SMASecromy and
platysmaresectionproduce a good rcsult in thcse patients, Ifindicated, a chm
implant will enhanceüc result. Usually a ¡etroau¡icula¡incisio¡ is not re-
quircd. However, if a dog-ear is present at the car lobe, it can be corrccted
with a short ret¡oau¡icular incision.

t.
 shorr-scú lace Lift: Evolution and ADDlic¿tions

Type III: The Fair Candidate (Late Fifties, Sixties,

Early Seventies)

l!4oderatecorvioalLaxily

Charact€rlstlca SurglcalPlen
Ag€lsi€flltl€s,sxli€s,or€arlys€v€ntl€s Op€nsubftenlálsuclioñ.a$bl6dllpoplásty
Signlicanijowls Platsrñáapprorlmállon at hyoldwlihcorc€ior wedge€xcs on
Mo@rat€carulcálskl¡ láxily SMAs€ctomy/plalysma r63€cllonor pllcallon
(lhinface)
Subméñlal/má¡dlbu áf lal F6movaloldog-6afInrsroaurcularsulcus
Plalysma bandson anlmatlon chn imDlant
if indicai€d

rhgldoclorny
Somgs6condary

They
Fair candidatesare tsually in their late fifties,sixties,or earlyseventies.
jowling,
exhibit significant moderatecervicallaxity,and submentaland sub-
ma¡dibular fat, Sigtificant medial platysmabands,activeon natural anima-
tion, may alsobe present.

The approachto type III patientsis via an opensubmentalincisioncomrectilg

subcutaneous unde¡miningwith the faceand lateralneck. Open lipoplastyof
submentaland submandibularfat is performedto exposethe platysmamuscle.
A 4 to 5 cm wedgeof platysmais removedat the levelofthe hyoid. The me-
dial borde¡sof the platysmamuscleare approximatedto defineüe cervico-
mental angle.Interal sutudng ofthe platysmato the mastoidperiosteumen
hancesthe jawline.Ifredundant skin is presentat the earlobe afterredraping,
it canbe removedwith a short ¡et¡oau¡icularincision.
2).6 Short'Scd Fa.e Lift Techniques

Tlpe fV: The Poor Candidate (Sixties and Seventies)

Signilicanijowls

Cervlcalskln
loldsbslowc¡cold

CharacielStlca SurglcalPlán
¡€e lat6slxlles
andssv€nil€s A slgnlilcsntcomprombé
jowls
Slgnilicánl Op6nsubm6ntal suctlon.asslst€dlipopásty
Poorc€Ílcalskin axlly PlatFmaapp¡oxlmallon at hyoldwhhw6dgeexclslon
SklnloldÉb6lowcrlcoid SIVAS€ciomy/plalysma r€s€ctlonor pllcÁtloi
Subm6nral/submandlbular
fat R3moval ot dog.earIn r€iroaudcularsulcus
Patysma bandsonanlmallon ChinlmplánlIt indioat€d
Bequresmor€€xl€lslveunderr,n,ng'orskin'edrapl.g
Betroáurlculár Incisioncanalwaysbe exi€ndsd

Poo¡ candidates are usuallyin their sixtiesand seventies,with significantjow!

ing and active,lax platysmabands.Skin folds and deep creasesbelow rhe
cricoid cartilageareoften prcsent,and cervicalskinelasticityis poor. Aldrough
thesepatientsarc not good candidates for short-scarrhytidectomy,this opera-
tion canbe offe¡edto them asa compromisesolutionthat keepsopenthe op-
tion ofextendingthe ¡etroau¡icularincisionifnecessary. Laterallyand posten-
orly, it is usuallyrecessaryto undermineover the mastoidand sternocleido-
mastoid muscle to obtain proper skin redraping. Excessce¡vical skin must be
tailored into t¡e retroau¡icular sulcus.
 Short ScarFaceüR: Evolution and Applicatio¡s 2t7

Toble 6-1 Evol¡io¡ of the Sho¡t-Sca¡Rhltidectomv

?átients Procedurc/Skinry"e
1990 I
Skinlift oniy
l99l 4
SAI neck
t992 3
\993 t2 All typeI prtie¡ts
t994 t5 ] llicxtioDor SMAsecromy
1995 35 Atl typ€sI and II
1996 44 clos€dsAL (neck)
t997 45 Plicarionor SMAscctomy
r998 50

TypcsI, II, III, andIV

1999 245
Clo'cd \u(flun.rssisrrdlipoplisry, rrcck,or open
2000
Plicatid or Strtr{sccromy
200t
SubnreDtal
plarysnrapl¿sty
2002
MajoritytypesI, II, andIII
2003 236
Mor€ plicrtionandimbrication
2004 249
SMASectomy
fcr debulking
2005 231
TOTAI, 2345
218 shorr ScarFice-Lili Tc.hniques

OperatfueOpeytiew
I,ATERAI SMASBCTOMY
INCLUDING PLAIYSMA RESECTION
Thc rcapproximationafter SMAS rcscctionis usuallydonc with interrupred,
buricd 2-0 and 3 0 PDS sururesplaccdin a verticaldircction and perperdicu-
lar to the nasolabialfolds. Plicationis usr¡allvdonc with interruptcd suturcs,
althoughin somecasesa runnütg closurcis morc eftrcient.

In thc SMAs-platysma¡cscction,thc lcvcl of rcsectionis supcrficialto tnc

parotid masseteric fasciarh¡t overl¡esthc ficial ¡rcrve[rranchcs.
The ourline of
thc SMASectomyis markedon ¡ txngcnt fiom thc l¡tcr¡l malareminenccto
thc ¡nglc ofthc mandible,csscntinllyin thc rcgion along the antcrioredgeof
thc parotid gland. In most patientsthis irlvolvcs:r line of rcscctionextending
fioft tlrc latcralaspectof thc nr¡lar cntincncctow¡rd the tail of rhc parotid
glllrd. Frcquentl¡ ort-ricula¡is
oculi ¡.r.rusclc
ñbcrcue cxposcdit tlte suDerior

5MAS.€s6clioñ
lsuarryo,{ondsov€r

andoúicula¡is
oculimuscle
Oplionalsubñenralincision;
uñd€ñrñ¡ñgconneclslateallywith
plalysmaappox¡maton Caul¡on zone
bÉyondpadoidi
mustslayin lhe
sameplaneas
SMASd¡sssciion;
r6s€cl¡on
¡ssále
ovor parctid

Sf\,lASresection
€xtendsnlo
poslerlor
necklo ¡nclude porlion
orp alysmamuscleover
 Shon Sca Fá.e Lift: Evotution and Applications 219

limit of the excision, which must extend over the mala¡ eminenceto elevate
the fat pad. Usually a 2 to 4 cm segment of superficial fasciais excised,de-
pending on the degreeof SMAS-platysmalaxity.

It is important to emph^sizerl\rt in petientt with thin f¡tcet, SMASectowyis not

perflrtned. Instead, plication and imbrication are designed to recontour and
augment the face.

In SMAS resection, I üke to pick up the superficia.lfasciain the region of the

tail ofthe parotid gland, extending the resectionftom inferior to superior in a
controlledfashion.When SMAS¡esectionis being performed,it is important
to keep the dissection superflcial to the deep fasciaand avoid dissection into
the parotid parenchyma.The sizeof the parotid gland variesfiom patient to
patient; consequentl¡ the amount ofprotection for the underlying facial nerve
brancheswill alsovar¡ Despite this, aslong asthe dissectionis carried superfi-
cial to the deep facial fascia,eusuring that only the superflcialfasciais resected,
facialnerveinjury aswell asparotid injury will be prevented.In essence, this is
a resectionofthe supedcialfasciain the sameplaneofdissectionin which one
would norma.llvraisea SMASflao.

SI,IASandplatysr¡a
ls vsrllcallo d€€pfascla

platy3me/S[,lAs

Submandibular

Futuresulurefrom
platysma/SMAS
subrnandlbulár
to ánt€dorparoiidtascia
(verlcalvecto4
220 Short-ScárFace-LiftTechriqucs

RESULTS
In my experiencewith pe¡formingmore than 2000 short-scarrhytidectomies
in properlyselectedpatients(rypesI and II), thc resultsand longevityare sim
ilar to my classicrh¡idectomy. Complications are simila¡ to Áosc of oth.,
published rh).tidectomy series.

Cornplicaüonsofthe Sbort-ScnrFaceüft
Hematoma r.5%
Facia.l
paralysis(all rcsolvedin 2 months) 0.3%
Infcction (abscess) 0.8%
Skin slough(minor) t.0%
Hypertrophicscars 2.00/0
Suturegranuloma(PDS) 3.5%
Ear lobe deformity 0.8%
Retroauricular pleating 2.0%

Af'tcr going through a pcriod of tryilg the shon-scarapproachon almost

all
rypesofpatients, I havclcarnedthc limitationsofthe tcci¡rique. Now, rather
than comp¡omisingthc rcsult,I do not pcrform short_scar rhytidectoÁieson
typc IV patientsand many type III paticnrs.Malc patientsusuallyprcsent
at a
later agc for rhytidectom%with morc cervicallaxiry and very few are candi_
datcsfo¡ the short-scartechnique.

Limit*tion oftbeShort-ScarFaceüft
Best for type I and II patients
Earlierneck¡elaxatioflo¡r rypeIII and IV paticnts
Morc ear lobe sca¡rcüsionson qpe III and IV patienrs
Rarcly applicablc for malcs
 \h,, r S.rr f.r.r I itirI r,,luri,)r f¡ \ffLi..ún 221

CASE EXAMPLES
Slrolt ScarFaceLiti fbr thc'I'rpe I Patient PlicationO¡rlv
ArstbcticAnallsis
T h i s , l l l r c ¡ r o l L ll r r n r , r nh ¡ r l c . r r l vj r x r l s . r r r rclc l v i c o t i c i rll¡ ¡ i i r r .I l c r l ¡ c e t . L s
t h i n ¡ n t l l r o r l rf i r l r r l . r \ t t r o r h s h c . l l \ . \ \ u , , r ' . l r r r t ¡ t l i n . r
l),,n\j,rl r(l \\ils
q f c r t l \ a ( ) n c c n t c.(rl L ¡ r ¡ ur cl ¡ r o ¡ u r i c f l . rsrr . l r \ . l l l dp ( r s l c r i ( h
) re i | l i n cr l i s r . u p r i o r r .
Hcr lrlcscnrrtior nt.rtlcltcr..t tvpc I ("r11c.rl" l ..rtrlicl¡rcfir shorr st ¡r. lltr.rirlc.
1 1 ) n r \I.I c r t l t i f i c c . l n r lh o l L ¡ r c h c e s r r . . h L . r tl r r . r r e , $l i r l r , . l L , , n , l l t l
¡rl
l r r r b r i ( ¡ t i ( r1n( ) . 1 r 1 ¡ ¡ c l ) t . r ¡l r. cJ c o n t o Lhrcr .r l i t c .

I
áe

)
222 Slriú S.rr f¡.. L ri I..hn,l,.\

Surgicol Plon
fhc tlc.rtncnt consis¡cdoi:
. I-oc¡l ¡ncsthesi¡rrith irrtr.ncrrorrs
pr-oPolirl
. Sinrplcshort sc.rlfircclif-tlith plicrtion ofSN{i\S.rrrd¡l.rrvsnr.r
. No 1iIosu.lion ¡¡r rcnrolrl of lirr
. N() sLrl)r)rcrrt.rl
\\ ()rli

PostopcratipcRcsnlts
'l
h c ¡ . r r i c n t ' sI v c ¡ r - l ) ( ) s l ( ) | c f r l irrccs u l l sL l c n r ( ) n s t r r¡ tnc ( ^ c f r l l . h ¡ n u . ci r r l i
e i r r rl h i r p cr o ( ^ r r l .\ i f l ) . ( ) r r c . f i ( ) ror l j o r l s . r n d r n i ( l l i . c¡ n ( l c n h . 1 n ( c n r c(nrL1 '
e h c c l iL r o n c sl.h c l ¡ ¡ c r ¡ l v i c w r h o r r sr c . l i c ( ) r r c c l i ( )l nr i l l r p r c s c r \ . r r i ( () )r lrl h c
h ¡ i l l i n c¡ n L li n r P c ¡ r c I t i 1 'sl e, , r r s .

G6 b6
 \r!r s ! r L l t r . r l _ i t r 1 , L u r t . ¡ t r n \l 1 n . . r r r , f . 2,23

J
t
I
- r
: ¡ ¡ r r s . r f f . ( r I i l L l ¡ , ¡ , r , l L*

Shott-Scar Facc Lilt lbr the Trpe II Paticnt

Plication Orrl¡'
AcstbeticAualysis
l l r i s 5 5 r c ¡ r o U r v o n r ¡ nh ¡ r l r r r o t l c r ' . rj tocl l i n g r n L l e e l r i c ¡ r l i c i ¡ll¡ r i ¡ r l i t l r
r ¡ i n i n ¡ l s L r L r ¡ r c r rl t¡¡t l. F , r c c sssl i i n. r r t l J i r o t l t h c u p p c r ' . r n kt lr r r c rc i c l i d sl . -
l ) r - c s c nS1h. cl c l ) r - c s c n r .cr(t lr ' P cI I t " e r x r i i " )c . ! l r d i r l . r1t ci ¡ rr h r ¡ r ¡s c ¡ r r l r \ l i i l c a
¡ ¡ ¡ n r t .l i r n r ¡ i n t ¡ i nJ i ( j . r fl i i ¡ r r ( lr r s l i ) f cl i ( i r l t i r l l r r c s s ,¡ .rrl i e , r t i oonf t h c S ñ 1 . \ S
.ln(l l)lrtr\nr.r\ .r\ l)(rfi)rrrrr(1

Surgical PInu
'l'hc
t r c ¡ t r c r r tc o n s i s t c ot it :
. L o e . r.lr c s t l t c s i\¡\ i ¡ h i i t t f . t \ e r r ) Lpt r ( ) l x r l i ) l
. t I \ t \ ' . r ) , 1 l , , r r c rl ' l c 1 ' l r . r r , , ¡ ' l . r , r r
. S i r ) ) | l c\ h l ) r l s c ¡ r ' t . r cl ci f t l i ¡ h ¡ l i c . r t i o no l r h c S I l . \ S . n t l I l ¡ ¡ v s n r . r
. ( i ) n s c f \ l t i \ c c l { ) s c dn c c Ll i ¡ o s r r e t r o r r

I'ortol,trñti i,t Iltt /| Itl

l l r e ¡ . r t i e n l r I \ c ¡ f ¡ ( ' s l { ) p c f . r r i \ cl r ' s u l ¡ i i c n r ¡ r n s r ' . r t cfsc c \ l ¡ h l i s h r r c r r r( ) l . l
r ( ' L r t h l i r l (, ' \ . l l l i e i . r l s h . r ¡ r cc. n l r . r r . c r ) r r n lo l t h c s u h r r . r l . r r e s i o . ¡ n ( l t h c r ' l i
h o n c s . . r r t l¡ o l r ' e i t i o r r( ) l ( ) f ¡ l ( ( ) r r l r r l i \ \ u f e sl h e l . ¡ t c l . rrli e r r i l c l ¡ o l t s u - . r l ces¡ .
f c . l i ( ) n ( ) l - t h ce e | r i t , r ll , r r r t v . u l Ljl, r \ l i l r er r i t l r l ) r ' c s c r ' \ . l l i r¡¡¡rl]t h c l r . r i r ' l j r ¡ e .
 5 l i . f t S . . ú ! . r . ( L i ¡ 1 :| \ , , 1 r t n n . r f d \ f f r . r ( n )r \ 225

@t { \ rfit
\i'
; --*
226 Short-Sctu¡áce-LiftTechniques

Short-Scar Face Lift for the Tlpe III Patient-SMASectomy

AestheticAnnlltsis
This S9-year-oldwomar had significantjowls and ce¡vicofacial la-ritywith mr-
crogenia.She had excessskin and fat of her upper eyelidsand representeda
type III ("fair") candidatefor short-scarrh¡idectomy. A lateralSMASectomy
wasperformedto reducejowl and cheekfullness.An upperblepharoplasty was
alsoperformedand a chin irnplantplaced.

SurgicalPlan
The t¡eatmentconsistedof:
. Local anest¡esiawith intravenouspropofol
. Open-necküposuctionandapproximationofdre medialplatysma
. LateralSMAsectomy
. Chin augmentationwith a Silasticimplant

PostoperaüteResalts
The patient's1-yearpostoperativeresultsdemonstrateimprovementin the fa-
cial shapeand midfacewith enhancementofthe cheekbones.Neck improve-
ment resultedfrom midline plarysmaapproximationand a chin implant. No
subplatysmalwork wasdone.It is importalt to note that rhytidectomycaunot
eliminatedeeprhytidsfrom the commissurefowl area.
 Slr. i S..f lr.r I ilir lr,rlrrn)r 'r\l'\tflr'Irf\
)2:

/
,-;
<:*
*
zY ?

),

o\
v
t:
I 'i[1'¡

(ü
/'l
4. *d $fF (
,,(

\
v[ '**
/
,t
,I '/
't**

lrf i 'i 'i!\ \

'\\\¡l

rü;'x-;
t'.
I ,.q $ *r¿\"
'¡

/
L t!
.rofr
'il
224 short s.ú Face Lift Techniques

Short-Scar Face Lift for the T¡,pe III Patient-SMASectomy

AestheticAna.lltis
This S3-year-oldwoman had alwayshad submentalfullnessand lack ofcervr-
comentaldefinitior. She representeda type III ('fair") candidatefo¡ short-
scarrhytidectomy.

Surgicnl Plon
The treatment co[sisted of
. Local anesthesiawith intravenouspropofol
. Open-neck liposuction and approximation ofthe medial platysma
. Latelal SMAsectomy to reduce facial fr.¡ll.ness
and jowls

PostoloretiyaResalts
The patient's l-year postoperativeresultsdemonstrateimprovementin the
neckandjowls andreshapingofthe face.Despitethe factthat no subplatysmal
work wasdone, the lateralview demonst¡ates overresectionof subcutaneous
fat leavinga slighrsubmenralhollow and prominentptotic chin.
 ;#. \v v Y
uNr
|€
:B
z ,.- .*.,\...r
:
t +,
|¡r¡
"l ,t
g**-
r
r3
?
É:
É
ü'7 \
.-b-
230 Short Sc¡¡ la.c LiliTcchni!ucs

Short-Sc¿r Face Lift for the Type IV Patient

AestheticAnalysis
This óO-year<rldwoman dcmonstratedcervicallaxity bclorv the cricoid cx-
tcnding to the sternalnotch. Shcwasr "poor" ci¡didarc fbr a short-scarf¡cc
lift, rvhichwould havccompromiscdthc improvemcntofher ccrvicallaxiry

Sargicnl Plnn
The treatmcntplan consistedof;
. focal anesthcsia
with intravenouspropofbl
. Open-neckliposuctionand approximationofthc mcdialplatysma
. LateralSMAscctomv

Postoteretive Resalts
Although this pxticnt ¡ras¡ nicc i¡rprovcnlcnt af'tcr undcrgoing short-scar
rhytidcctorrr¡ the p()stopcrativcrcsult dcmonstratcspcrsisrcntccrvicll laxiry
cxtcndingto thc stcrn.rl¡rotch.The p¡ticnt wasnot happyand rcquircd rrcck
rcvisit¡nwith;r classicrctroar¡ricular
i¡rcisio¡r.
This much ccrvicallaxirycln
only bc corrcctcdrvithwidc through-md-through undcrmiringand rcmoval
t>fcxccssski¡rvi¡ thc rctro.uriculxr
occioitalincisi<¡n.
s b . ¡ S . i , F r . ( I r r l : l \ 1 , i f n o i r ¡ r i r \ r r r r l i ! . , r i 1\ 231

=l
shd( s..tr Ir.e Liri l..h¡!u!\

Short-Scar Facc Lift for the Type IV Patient

Aestbetic Analysis
'1
fhis ó,1 vc¡r olci tornln is ¡ vpe IV ( " P ( x n - " ) e i r l d i d i r lirr
t c ¡ slrr;rt sc¡r'lif_t.
Shc dcnronsoirtetlp<xrrskin cl¡sficit! .urtlelccPhot izr¡rt¡l ccrvic¡l cfcilscslrc
lol the cricoirl.

Surgi.cnlPIan
Thc trc¡t¡¡cnt consistcdr¡tl
. Sh(r't-sc¡r'rltvti(lcct()ntv
. SMAS plicati(rr
. (lhin impl¡nt

Postopc l.ttti w R¿t tt lts

'l-hc
prrticrtt'sI lc¡r |ostoPcl.rtircrcsLllrs sllorv¡liltint.tl illrPrrxc¡tcltt ol tc
r r c c k , \ \ i t hi c c c D l r ¡ r t i ( )0rfl t h c c c r v i c . rel r c r s c sl.l t c p o o r . r . c s t r l ct n t r ¡ r s r r . r t c s
Iirrr¡¡.lti()¡s ()l lhc sll(rft seirr-tcchnic¡uc li¡.tltis t||c r¡l l.r¡ticn1, rr.hoh.rscrccs
sirc slrn (l¡nr¡qc ¡nd l)(xn'skinclirsli.irv.lltc Ircttcr¡ppro¡ch rvrtrltl lrc¡eli.
sic rhvt¡!lccknrry\ irh s(¡l)ntc¡trlincisir¡r¡¡ltl rr irlc untlcln¡i¡inr¡ firr nt¡rintt¡nr
skin lcclr.r¡Tinu.
 Short Scr Fá.e Liftr Evolution ¡nd Applicariom 233

Ean'gi.calPearls
. The best candidatesfor short-scar rh¡,tidectomy are younger, with bet-
ter skin elasticiryard lesscerücallaxity.
. Pe¡form skin flap undermining under direct visualization to minimize
trauma to the subdermalplexus and preservethe layer of subcutareous
fat on the unde¡surface ofthe flap.
. Perform lipoplasty before elevating skin flaps and avoid oversuctioning.
. If activeprominentplatysmabandsare present,open the neckand un-
dermineto perform mediaJplarysmaapproxjmation.
. Plication is alwayspreferred in patients with thin faces.
. A lateral SMAsectomy pelformed when debulking is aestheticallybene-
ñcial.
. For maximalmidfacecorrection,extendplicationor SMASectomyover
the malareminencejust short ofthe late¡alcommissure.
. If a lateralSMAsectomyis performed,keepthe dissectionsuperficialto
the deep fasciato avoid the parotid gland and facial nerves.
. After plicationor SMASectomy,the lastsuturelifts the malarfat pad se-
curing it to the malarfascia.
. Finallf not every patient is a candidate.for the short-scartechnique;
some will benefit more from classicretroau¡icularand occioital inci-
sl0ns.

BIBLIOGRA}HT
Bal(erDC. Complications ofcervicalrhytidectom¡Clin PlastSurgI0:543-162,1983.
Bater DC. Deepdissectionrhytidectomy:A ple¿fo¡ cautioD.PlastReconstrSurg 93:
t498-t499, t994.
Bater DC. LateralSMAsectomy. Pl¿stReconsüSurgI00:509-513,1997.
Bater DC. LateralSMAsectomy, Semirllast Surg16|4IT-422,2002.
BakerDC. Minimalincisionr\tidectomy (shortscarfacclift)with lateralSMAsectomy:
Evolutionand applicátion.AestbeticSu€ J 2l:14"26,2001.
BakerDC. Minimalincisionrhytidectomy (shortscarfacelift) with latcralSMAScctomy:
Oper¡tirg strategies.
AestheticSurgJ 21:ó8-80,2001.
BakerDC, ConleyJ. Avoiding facialn€rveinjuíes i¡ rhltidectomyt Ar¡tomical variations
andpitfalls.PlastReconstStrg 64t78I"795,1979.
BakerDC, HamraST,OwsleyJQ, et al. Tenyearfollow'upon the twin srudy.Presented
at the Annual Meeting of the Am€ricar Societyfor Aesthctic PlasricSurgery,New
Orleans,LA, April 2005.
Cor ey J. Face-LiftOperation.Springield,IL: CharlesC Thornas,1968.
Dufft MJ, FriedlandlA. The supe¡ñcial-pláne
rhytidectomy revisited.PlastReconstr
Surg
9311392-1403,1994.
slrorr'sc¡rFacc-Liftltchniques

Mitz V, PcyronieM. The supcrficinlmusculo-aponcuroticsystcm(SMAS) in thc parotid

and cheek¡rca. Ilast RcconstrSurg 58:80-88, 197ó.
PassotR. La chirurgie esthctiquedesridcs du visrge.lrcssc Med 27:258-262, 1919.
¡itanguy I. Facial cosm€tic surgcry: A 3o-vear pcrspective.Pl¡st Rcconstr Surg 105:
r5t7 - t526, 2000.
ReesTD, AstonSJ.A clinicalevaluetion ofthe resultsofsubmusculo-aponeurotic disscc-
tion and fix¡tionin facelifts.PlastReconstrSurgó0:851-859,1977.
RobbinsLB. F¡ceand necklift. AcstlrcticSurgl 19:7077, 1999.
SaylanZ, 1'hcS-lift:lessis more.AesthcticSurAI 19:406-409,1999.
Tipton tB. Shouldthc subcut¡ncous tissucbc plicatedin r fircclilif PlnstllcconstrSurg
54tI-5,1974.
'lbnnard
PL, Vcrpaele AM. Thc MA(IS-LilirShort-Scár Rhytidcctomy. St Lolis: Quality
McdicilPubl¡shing, 2004.
'lbnnard
B Vcrpaelc A, MonstrcyS,ct al. MinimÍll¡ccesscran¡rlsusfrcns¡on lift: A modi
ñcdS-l¡li.I'hst lteconstrSurg109:2074-208ó, 2002.
 Combined
Approachesand
Synergistic
Procedures
 The Anatomic
Basisof Platysma
l¡
)uspenslon
Daniel Labbé . TulienNicolas
234 Combi¡ed App.oachcs¡nd SFergistic Proccdurcs

D
I latysma suspcnsionprovides a complementa¡y t¡eatment ofthe aging neck
when the¡e is an imporant cutaneousdistention or markcd platysma bands.
We use platysma suspensiontogether wiü platysmapexyand the MACS-lift
suspensionin ccrvicofaciallifting procedures.The platysmasuspensioncan also
be used alone in the caseofa pure cerücal lift.

Platysma suspcnsionis based on the same conccpt as the MACS-lift and is

ficundedon thc sameanatomicpri[ciples (deepgliding plane,plication, an-
choring to a solid fixationpoint, and Loré'sfascia).

BMBRTOLOGYAND ANATOMY
Bnbryology
The facial musclcsand the platysmaare dcrived from the samebranchial arch
(arch VII or hyoid arch) during cmblyogcncsis.They a¡c innervated by thc fa-
cial ncrye and scparatcdfiom the deep c€rvical structurcs, which havc a diffe¡-
ent embryologicodgin.

At a gestational agc of 9 to l0 weeks, the platy$maconsistsmainly of myo-

blass. Mcsenchymalcells, which arc considcrcd thc prccursors of thc platys-
mal fascia,surround thcse myoblasts.Thcre is an additional mcsenchymallay-
er bctwccn thc stcrnoclcidomastoidmuscleand the platysma.This laycr is not
attached to the platysma.In a fetus of 13 to 14 weeks' gestation, thc platysma
is situatcd immediately beneath tlc skin. Thc sternocleidomastoidmusclc is
locatcd undcr the platysma and surroundcd by thc supe!ficial ccrvica.lfascia,
The fasciaofboth the platysmaand t$c stclnocleidomasroid musclegüdeon a
thin layer of areolar connectivetissuc callcd thc superf,cialcetvicalfatcia.
 The A¡atomic Bsis ofPlatvsmaSusDension 239

Anatony
TIteSMAS
In 197ó Mitz and Peyroniedescribedthe superficialmusculoaponeurotic sys-
tem (SMAS),which consistsofa continuousstructureofelementssituatedin
a singleplane.The superficialñsciaat the undersurface ofthe subcutisis unl-
lbrm and homogencousover the whole body surñce.The posteriorborder of
the SMAS is attachedto the audcularcartilageand the tragus,coversin a
rathe¡denselayerthe parotid¡egion containingthe parotid fasciapropcr,and
is in continuitywith rhe muscularfibersofthc orbicularisoculi muscleand thc
fiontalisr¡usclec¡¡niallyand with thc fibcrsofthe platysmacaudally.

The cheeksconsistoftwo viscoelastic layers,the skinand the SMAS,which arc

denselyconnectcdby fibroussepta.It seemsthat all theseelementsfo¡m one
functionalunit capableofexecuting the intricatcnovementsoffacial expres-
sion, The SMAS itsclf is á compositetissueconsistingof collagen,elastic
fibers,and adipocytesin a viscousext¡acellularmatrix, It hasthe typicalvis-
coclasticpropertiesofreptation, stressrelaxation,and hystercsis.In certainill-
dividuals,after placingtcnsionon the SMAS during surger¡ relaxatioris ob-
serveda few wecksto a few months after the surgery.In contrast,this rclax-
ation ca¡ be obscrvcdin skinjust minutesaftcr thc surgicalfiilleLrver.

ThePlotysma
Thc platysmais a very wide, thin quadrangularmusclecoveringthe anterolat-
eral region ofthc reck and the inferior part ofthe face.It ¡eachesfrom thc
thoraxto the mandibleand the cheek.Caudall¡ along the scapulargirdle, this
mmcle is attachcdto the Lrndersurface ofthc skin coveringthe acromion,thc
dcltoid, ¿nd the infraclavicula¡region. Distally,the musclefibcrs arc initially
distinct and separatcdfrom one anotherand rufl irr a mcdiocranialdirection,
graduallyuniting to form a continuousmuscularlayer.The platysmas are sepi-
late fron otre anothcrat t]reir origin and run obliqucly upward toward each
other.Veryoftel1platysmal6bersoverlapil1the midlirc ncarthe mentalregion.
240 Combincd Appr@ch.s and Sy¡c.sisric P¡cedurct

Superiorly,the platysmamlrsclehas the followi[g cutaneousaswell as bony

r[se!üons:
. Thc antcrior fibers inscrt in the skin of t}¡e mcnral Drotube¡anceaftcr
crisscrossingeachothcr.
¡ The middle fibe¡sinscrt into the inferior mandibularborde¡ and to thc
antedorpart ofrhe obliqueline, crossingthc fibersofthe depressoran-
guli oris and depressorlabii inferiorismusclcs.
. The posterior or lateral fibers are pardy in continuity with the latcral
fibersofthe depressorangulioris muscle;othersrun direcdyto the labi-
al commissureand the cheekskin.

angul¡orls

lablllnl€rioris
 The A¡áromic Bais ofPlatysna SupeDsiot 2+l

Inré's Fascin
The temporoparotid fascia,or fasciaof Loré, was describedin 1973 by John
Loré. It is well known by surgeonsfamiliar with the dissectionofthe t¡unk of
ttre facial nerve, in particular in the parotid gland. This fasciais located be-
tween the q-rnpanomastoidfissureand the parotid gland. It is one of t}Ie fixa-
tion points of the parotid gland aad is located immediately ante¡ior to the in-
tertragal incisure. I-oré's fasciais a very strong structure used as an anchor
point for platysmasuspension.
! 242 aoñbined ApproJ.he(rd 5)nergi'.!c¡rocedure'

TheAuricalop latysmaI Líg ament

The auriculoplatysmalligament was fust describedby Daüd Furnas in 1989.
It consistsofa complexcondensationoffascia.It inse¡tson the dermisofthe
inferior part of the auricular region at tlre level of the ea¡ lobule where it is
consideredto merge with Loré's fascia.It runs obliquely downwa¡d and ante-
riorh and ends at the level of the posterior border of the platysma. Cranially
and posteriorly, it is in closerelationship with the skin of the inferior auricular
region and Loré's fascia.Cranially and anteriorl¡ it is in relationship with the
platysmaand greater audcularnerve. Deepl¡ it is in relationshipwith the
parotid fascia,and superflcially widr the dermis.

Zygomatlc
llgam€nt
 'I
h. \nrnni. ll.s\ {n l)ll\sNr su\l)(n\i,trr 243

Functionrl Anatomy
Gliding PIancs
In thcir rrorl<on gliilin¡l ¡rlrrrcshcl\\ecn scp¡r.rtcstl'uctulcs,(iirrbcrtc.rLrcl .rl
¡lrlnrtrlcrl rhc thcorv of l¡nrcllrr'sp.rccs.rn,rl tlcrclo|crl thc nc\v c()r)ccl)tol .l
slrrrclrrrccrrnr¡roscrl ol nlrlti¡rlc nriar-olxcLr()llr units. In ¡rc.rsrrhclc nlolc int
p()rl¡nl k)nsiturliDxltlis|l.rccnrcntis nccilcrl.thc \'rrcuoles in thc \tntfturcs irrc
nlrre dclic¡tc i1n(lltrcirtcrin nunrhcr.A!.irrqdefi)rmsthcscstrr¡ctulcii]n¡ di\
tufbs lllc b¡sic l()nusofthc tissucs..r ¡hcn()rncn()nthil c¡lr irc obscrrctl ilt tltc
q i ¡ l ) i n so f i r r r r r u n r¡l l i c r ¡ s u r ¡ l i . ¡ li n c i s i { r r l. h c ¡ r c o l ¡ r s t r r ¡ c t u r c r ' ¡ r i c s l r r I c
gion. e.rtrsing rliflcrcnccsin qlidirrq..lp¡citics.rnrl tlis¡l.rccntcnlrntl)lito(lcst(
cortlirrutr¡ thc tissucs.l his cr¡rl.tinsth.rt¡rhllsnr.rsus¡rcnsion irlk¡r's.r tlillircnt
r c I o s i t i o r l i ¡ l i¡r:e e o l r l i nt¡,¡r 1 h c . u r ¡ t ( ) n r i c . l f c i.nr sr c l . l t i ( ) r ) \ l )ri op t h c g l i L l i r r g
¡l.rrrcsirrrdrlccpeonrrcctions.

Spasn nnd Contracttu'c oftbc PIlttysrm

\\'llc¡t tIc¡¡inq thc scqrrcl.rc ol tici.rl p.rlsr'.lxrth tltc P. ¡hzctl sitlc ¡nil rhc
s p . r \ r n . u rsr lr n k i n c t i ce o n l . r c t i o l rosl t h e h c r l t l t rs i r l cl l u s r l r c l f c . l l . ¡ . I t ] r h c
p l ¡ l \ s n r ¡t h c s cs l ) . r s r r \ . u rci s i l r l c . t sp l ¡ t r s n t ¡ ll r ¡ n t ] s , , r t i c lct f c ¡ f i n gl,h c J : l l \ !
iru¡rr-cssion ol skin l¡ritv. l lrc tr'c¡tr¡cnt li)ftllesc c¡¡ttlitioltsis re¡c.rrcilbortr
l i n L r ntro r i n i n j c cito n s .u h i c hi r ( l . i f t l t c l r \ c l o l t h c n t o t r c n d ¡ l . t t ct { , p . u r l v z e
r h c p l ¡ l \ s m ¡ , . r ss c c r irr r t l r i sp ¡ l i c n t l ) c f i n - ¡cn c l¡ l - t c lo n c s c s s i o or rl l r r ¡ r ¡ l i l l L u l
t()\in t() t¡-cr(unil.ltcr¡lsl)¡sm{'t lh. l)l.ll\srrr.r nruscle.,{sin{ of ¡hc neckcon
s i s t so f p t o s i st o u c r h c r | i t h s p . r s norl - t h c¡ r l ¡ t r s ¡ ¡ r .l h i s l n c ¡ l t s1 l r . rl t) ( ) f L r l i D U n t
torin c¡D bc Lrsctllrclir|csrrrqic.rl ¡)l¡t\sn]¡ sLrsl)cnsir)n l(' p¡r¡lrze thc pli1lrsn...
tlur-irr¡:, t hc ¡r rsto¡rcr.ll i!c h.irlirrq¡(f i(xl.
244 CombinedApp.oachcs
and Sinergisriclrocedures

SurgicalAnatomy

Ootemlnng thekeypoini

Traciionoñtho koyponl oflh6 plalys¡¡a

We pcrformedan anatomicdisscctionon 10 freshcaclavers (20 hemif-accs)

to
developthe techniqueof platysma suspension in associationwith platysrna-
pcxy.ln Dr. JoelFeldman'sdiscussion ofour articlcpertainingto thesedissec-
tions,he inquircd aboutthe relatioNhip betweenplatysmasuspcnsiofl and the
auriculoplatysmalligamentofFu¡las. This questionbecamethe impetusfor a
secondstudy in which u'e soughtto detcrmile this relationship.
 '1-he
Anitdnic llisis oflhivsni Sú$.nsi('t 245

Our scco¡cl stutlv rr,¡s pcrfi)r¡rrcd on liyc c¡d¡rers (10 hc¡lificcs). This studv
clc¡no¡rstriltcclthit the ¡uricul(4)lxtysnrrl lilirr)rcnt of l'ur¡r¡s is i¡r co¡¡ti¡rr¡itv
rvith the supcrficirlparotid fisci¡.rntl ¡ctr.r¡llycr)nstit!rtcs thc pl¡n's¡¡ir¡sus-
pc[s()r\, liganreút. Thc kc¡, ¡roilt f'<rrthc pl:rtvsmirsrrs¡rcnsionis filtncl using l
solicl ho<¡k and, rvhcn placcd rrnclcr'\'crtic.rl tcnsi()ll, iruricul(4)lirtvsnl¡l Iig¡-
mcnt (ligirmcntof Furrus) ¡rlicltion is irclriocd. Furtlretntorc,rhe ¡r¡ricul(,
pl¡tysñal ligi¡¡nc¡rt hrs rr stlong fin slrirpcrl inscrtion on thc cr¡r)iolx)stcri()r
D¡lt olthc ol¡lvsnr¡.

ln surrrmlrr',thisseconrl¿nato¡licstudv h:rsdenronsrrrteclrh¡t p¡¡nsrnJ sus-

¡rcnsionl,ith plat¡'snrapcxv
in flct corrcspondsto plicirti(mof thc ¡Ltriculo-
plitysmalli!¡arncrtof Furn¡s.
246 CoDbioed App¡o:ches ¡nd St,ncrgisticlrocc.turcs

Tlis anatomic u'ork has allowcd us to nake obser\,!rtio¡rsconccr ¡g the aging

ofthc ¡cck. The traditional theory ofaging ofthe neck ancl plalvs¡nais bascd
on a postcroaitcrior gJiclingdirection ofthc plaqvsma.Our anetomic obsen'a
rions havc denonstrated that aging of thc platysna takes place ¡long ar
oblique rcctor orierfecl dow¡rvirrd and anteriorly resulting liom distension of
the auriculoplatysmalligament of Fu¡n¡s in this dircction. At the same time,
thc posterior border ofthe plarysna stays6xed in the anteropostcrior dircc-
ti(D. At this lcvel the insertion ofthc platyslnais fixed and thereft)rc docs rrot
:rllow thc pl¡t)'sma to glide anteriorly. This meanstbat lging takes placc in l't
obliquc clircction mairrly dorvnlvirrd and discrctcly anteriorly.

V l
f
..,

{-,**
 nlc An¡rcmic Büis ofptárysmaSuspcnsion 247

INDICATIONS AND CONTRAINDICATIONS

We.conside-r platysmasuspcnsionto be a usefulcomplcmentto
the MACS_lift
tcchniquefor treatmentofa difficult neck. platysma
suspcnsion.cpt.e, ttc
platy.smalsururc(first loop) ofthe MACS_1ift. As the kcy point i, ptJJ _or"
caudall¡ the axisis still essentially
verticai.This plarysmapcxy tr."i, ,.e¡on,
or rne neck. Howevcr, the submentalrcgion remains "lt
difficult to trcat and
sometimesneccssitares an additionalsubmintalincisionto pcrfo;";;.;;,i",
ofsuprahyoidplatysmalbands,an excisionofsubplatysmal
Lt, o. ¿";;;;;;r.,
platysmaplasry

In our vicw, the platysmalsuture of the MACS-lift should

be rcservcdfbr
necks.with.a-mild laxity or youngcrwom€n,whereasthc platysma
susDension
rs rndtcatedtor corrcctionofmorc difficult nccks.platysma
suspcnsiorr allows
a more cfficicnt repositioningofthe platysma-skin coÁplex, alb.i, o, ,¡. ..rr,
exrendingto a degreeinto the hair-bcaringskin to
-.1-1::,::"j"*,*
¡Dsorb :"cision
anclrescctthc skinexc€ss. Bccauscwe arevcry satisficdwith th-eplatys_
ma suspcnsion, wc tend to readilycxpandour indications.

PREOPERATIVB PIANNING
Tl':.:h.p,:r dcscribcsprcopcrativeplanning of a purc
cervicallift. For the
mlddtc anclsupcriorthird of the faccwe follow a preoperative
plan similarto
that for th€,MACSlift techniquedcscribcdby Tonnarcland
Vcó*,"];;&,
umc I, p. 70).
214 Co¡,LrinedAppu.bcs ¡n.l S!ncryisti.frcc.drrcs

Assessment of Excess Skin

First, thc amour-rtofsl<in excessis evaluatcdrt thc lcvel of the enterior cervicrl
trienglc, and thc sübmentrl end medi:rn supraclavicularregiorrs.

Submand
bularlria¡ge
Maiorslpraclavcuar lossa

Sternocle¡dorñaslo
d r€gion

S u b m a n d i ba! r t r a n 9 l e

Omolracheá( ange
cuar lossá
[,lajorsupraclav
Slernoce domasloidreg on
 The A¡atoni. Básisof PlatysmaSupmion 249

Subñándibu
aririangl€
Cárotidtdangte

Subm€¡tal
lriangls
Si€mocl6ldomastoid
reglon

Itlajofsupfacavicular
fossa

Cárotidtriangto Submándibu
arlriangle

SlomocL€ldomaslold
€glon subm€nia
irianglo

MajorsupEclavicu
af tossa
250 Comblned Approachesúd Sy¡ersistic Procedures

Assessmentof Platvsmal Bands

The eflect ofplatysma suspensionon the anterior cervicalt¡ia¡gle is simulated.

ih€ k€ypoi¡t-
Det€mining

Ma|king
otihesuüahyoid onánd
bandrasect
ski¡Inclslon
submonlal

Next we look for anterior,median,andposteriorpl¿tysmalbands.At this mo-

ment, it is detenninedwhethe¡a botulinum toxin injectionwould be bene6-
cial, and if suprahyoidplatysmal band resectionis necessary.Hlpertoniciry o¡
spasmofthe platysmaand the depressoraogulioris musclesis evaluated.
 Thc AnatomicBásisof?láq'srñaSusp€nsio¡ 'EI

Assessmentof Cervical Fat

We also evaluatepreplatysmaland subplatysmalfat accumulation in the sub-
mental areaaod t¡e global fat contcnt of the neck.

Assessmentof Scars
Finally, the position and quality of eústing scarsare asscssedto adapt rhc
placementof futurc incisions.

We alwaysstart our cervical lift with a platysma suspensionwith a plication

of the auriculoplatysmalligament of Furnas, P¡coperativeiniections of boru-
linum toxin (Botox), rcsectionof thc suprahyoidplatysmalbands,a cervical
suction lipectomy, and/or a open subplatysmalfat rescction may be per-
formed, basedon the findingsofrhe preoperativeassessment,

PREOPERATIW BOTULINUM TOXIN IN'ECTION

Injection Methods

Botulinum toxin injectionsarc performed5 to 50 daysbeforeüe sulgicalin-

tcrvention. Thesc can be performcd by the surgcon or a dermatologist. Thc
platysmal bands are in;ected dirccd¡ and the anterior, median, and postcrior
bandsarc revcaledby askingtic paticnt to conrract their platysma,alsoknown
^s the w@netrver0f Babiuki. The lnjectiLonis performed during the muscular
contraction. The level of thc injcctions is int¡amuscula¡or beween the muscle
atrd the skin, but neverunder the platysmamuscle.Everyplatysmalband re-
ceivesthree to four iniectionsof2.5 unis of Botox.
Conblned Approaches
aód Syne.sisticProcedures

Complications of the Injections

Complicationscanoccu¡when the botulinum toxin is injectedunde¡neaththe
platysmaand when too high dosesare used (for example,speechproblems).
With the injectionspe¡formedasdescribedhere,not a singlecomplicationwas
encounteredduring 3 yearsin more than 90 cases.

Advantages of Botulinum Toxin Injections

The goal ofthese injectionsis to pa¡alyzethe platysmain üe preoperativepe-
riod. Platysmacontractionpostoperativelyincreasesthe risk of tearing the
musclefibersat the suturepoints. Preoperativebotulinum toxin administra-
tion allowshcaling under the best conditions.Paralyzingthe musclemakes
it easierto repositionthe platysma,eliminatingcurarizationwhen performed
under generalanesthesia. The main advantage,however,is the avoidanceof
platysmaltearingat the key point, especiallyin elderlypatientswith thin and
atrophicplatysmas and in patientswith hypertonicitywith spasmofthe platys-
ma (permanentald thick anteriorplatysrnalbands).

OPERATI!'E TECHNIQUE

I(ey Elements
. Preoperative testingofthe key point ofplatysmasuspension (see
p.250, top)
. Intraoperativedeterminationof the key point with a sturdyhook
. Abselce of(o! no) subplatysmal undermining
¡ Reinforcementof the key point by plicatingthe ligamentof Furnas
with a runnins suture

Thc surgeryis performedunder local anesthesia with sedationor premedica-

tion, or generalanesthesia
with o¡al intubation.The tube must be firated in a
medianposition tating carenot to distort the labiálcomrnissureor the lower
lip. The tube hasto remainfree ofthe ce¡vicomentalregion.
 Thc Anatonic Básisof Plaqsma Suspension

mafkngsiprsaurlcular
Pl€operalivs inclslon
accordngto Guyuroñ

The temporalincisionis madeaccordingto Guyuronand then descends along

the traguswith a backcut in the inferior part. The incisionruns a¡ound the
lobule at a distanceof2 to 3 mm and then continuesretroauricularly, crosses
the retroauricularskinhorizontallyat the levelofor abovebut neverbelowthe
retroauricularmusclc(which is visiblewhen the pinna is folded forward), and
then followsthe hairlinei¡ an undulatedfashion.Theseundulationspreventa
hairlinestep-offdeformity,

The ancho¡points at which the suturesdescribedby Tonnard and Verpaele

will be attachedaswell asthc limits ofthe cutaneousundermininghavebeen
markedpreoperatively with the patientin the upright position.

!\4-renappropriate,the upperand lowcr eyelidcorrectionsand lipofilling areas

(nasolabialfolds,lips, and lower eyelids)aremarked.
Conrbnt.lApp,otr.hcs¡nd Sy¡rrgn¡r l¡rrcdnfc\

Each siclcofthc ncck ¡nd faccis infiltr¡teclrvith l00 ¡¡l ofnor¡nal s¡line solu
tion containinp! I rrrg ofepinephrine per litcr. Aftcr thc cpilcphrirc tekcs ct:
léct, rhe skin flirp is createclw itl-r thc Trcpsat scissors.Thc disscction is pcr
lórmeci in ¡ sLrbcutaoeolrs planc, prcservi¡g x fc\\, nillimctcrs of l'¡t olr top of
the plirtysÍlrlr¡ncl StrIAS. lt is essentialto visr.]¿lizcthc plitysnx so thlt its pos
tcrior borclcr can bc gr¿spcd. Thc first gcncr:rtion of f'¡cc lifis \v:rs rlso pcr-
firrmcd in thc sutrcut:rneolrspl:rne.

()trr clisscction,howcvcr,is nr()rcIinritcdin rhc entcriordircctionof thc ncc,.,

but nrorc cxtc¡clccicirr.rclirllyin thc rcgi()nof thc stcrnoclcitftrnr¡st()idurr¡sclc
t() ilclricvcrcp()sitioningofthc platvsnrr-skin conrplcxrvith e vcrticirlvcct()r.It
to pcrfirrlr thc disscctionin this tissucpluc to obtain ir lochingcf-
is cssctrtiirl
flct o¡r thc rcsultbv ¡clhcrcnccofthc cliflircnt rissucplucs.
 Thc A¡atoñic B¿\isof Plaq'rnaSuspension

The key point ofthc suspensionis determined. It is located about 3 c¡[ below
the mandibula¡ bo¡der, in the triangle formed by the borde¡ ofthe mandible
and thc anterior part ofthe ste¡noclcidomastoidnruscle.It is prcfcrablc to se-
lect a kcy point as low as possibleto obtain a vertical vecto¡ oftraction, which
will produce better definitior of the cervicoment¡l angle. If tl-rekcy point rs
too anterior, the vecto¡ wiil bc too horizontal and thc ccrviconental angle will
be lessrvell defurcd.
256 (,trnhrl.¡.\tf n,J.hc\ ¡n¡ \r¡., g\¡. lro...1u,e.

'lhc
L c vs L r t L I ics i n s c r ' t cLt lr c t r l c ctnh c p l ¡ l \ s r r r . rl l t h c l < c vf o i n t ¡ l l r l t l t c I i s c . . .
¡ r l l . ¡ ¡ c r ¡ t c i n l l ( ) f ( 4 ) ¡ f ( ) ¡l i cs lc i ¡ r v i t hr 2 0 r r o r l l c s r r l b ¡ b¡lrco r r o f i l r t r r r cr r rvt
I r n s L r t u r - lch. c l < c lp o i r r ti s d c t c n l i n c r lu s i n ! tl s t r - ( ) r lhg< x r lL<' l t ' ¡ r r l l i r rLgr ¡ r . r L
t h i \ l ) ¡ ) i r rur s u r l l vs l i ! l h t l li n f c r i o lt o r h r i r r s c f l i o r r l t h c I i g e n r c not f l ; L r l r i r s .

r\t this ¡oint thc ¡n¡crit¡ tri¡rrr:lcol thc rrcel< is rrcll rctlchncrl¡n(i lhc (lcrn.rl
..lti()D()f thc r)r.ln!lil)Lrl¡¡
borclcr'.r|rt1 Ihc.lntefil)rc(l$c()l thc stcrnrrlcitL¡Dr.r:
'lhc
¡oid ¡rLrsclcis clc¡r-. lrJalil)rri\ ¡irrlc(l.lt rcp()siti()ning tllc Pl.l(r\¡l.l Jl)(¡rl
-l
.i to cnr in ¡ cl¡ni¡l ¡ife.ti()tr ti) le¡cfir¡c thc .rllcri()f bor(lcr ()f thc \tcfn()
clcit|rrr¡stoitl rnLrsclc irn(l thc nr¡¡rr.lilrul.r'lrr¡rlcr'..rnclto liii lurl sr,p¡rolttlre
sLrtrnl¡nclibulrrr gl.urrlbr tiilect lali()¡r()ri thc i.rsci.r slrpcrhcillis.lhis kcv sL¡
fLrr'cis.r pLrrscsrrinq sLrtürc()t thc plxtvsrn.r r¡r(l ¡ sirrrplciritc in L¡rlc's lisci¡.
'l
his plrn sntirlsr¡spcnsi()n .lnd plrfvsnr.ll)c\v.Lt¡hc lct cl of Lori's i.rsci¡c.rtrscs
-l'hc
rr ¡lic.rtirrn()fthc itlriculr)pl¡lrsrlr¡lli!,¡r)rcrrtol-llurn:rs. pursc \lfirlq !lc
siqrrol'thc suturc:rllowsiinc furrirr!l()l thc pl¡t!\nrr susfcnsi()n¡n¡ ilclticvc\rl
\¡1nrq l)lirlvsrn.rpc\\r to Lori's lisci¡.

Jr-
 Th. Anátohic BasisofPlag,srh Surpcnrion

A posteriorreinforcementand reclrapingsutLueis placedbctweenthc posteri-

or platysmalbo¡der and üc aponcurosisof tl¡e stcrnocleidomastoid muscte,
This sutu¡c docs nor add any vcrtical lift. According to Tonnard and Verpaclc,
SMAS plication is achieved, completcd with a running suturc betwecn tnc
SMAS and the parotid fasciaas describcd by Fogü, which correspondsto rhc
suturcachicüngplicationof the auriculoplatysmal ligamentof Furnas,

For the necklift, the continuoussutureruns betwecnthe posterior¡cinforce-

mcnt and red¡aping suture describcdabove and thc parotid fascia.This suture
rcinforccsthe key point of the platysmasuspension,achicvingredrapingand
plicationof the ligamentof Furnas.

\44renperformedwith a MACS-üft, the running sururedescribcdby Fogli is

continuedto the zygoma.
258 C{r¡bi¡rcd App.ofuhcsiód Synergiricl'roc.durcs

Ths keypoinlis r6inlorc€d

silh a running
suture
belwee¡!h€parolldlasciaa¡d1hÉláscia
ol theslon@leidomasloid muscle.

Next tlrc skinis exciscd¡nd rcdllpcclin a ncarlyvcrticlldirection.Usingthc

fbrccps,2-0suturcsirrcplaccdjustbehindthe c¡r'fhc skinrcscctir>n
Pir¡r'lgLly
shouldbe strrightbcc¡uscthc zigzagincisionon the no¡rclisscctccl s¡clc$ill
irbs<¡rbthc skincxccss.1hc skinis rcdrapcdu'ithoutcxccssive tcnsion.Suction
dr:rirsarcpllceclin caclrsidc,andthc closulcis pcrfirnncdin nvo phncs.Usr
llly cachsideis trc¡tcd irntl sutlrredsepirilcl)'. lt is, hourvcr, llso possiblcto
pcrfbrm thc disscctionscqucnti¡llvon both sidcsand placcthc suturcssirnul-
t.ln(ouslrt(' lrcncrrcgrrl.r¡cthc pl.rnsrrt.t
suspcnsion.
 t59

{ü

. \ i o ¡ r 1 ' r c s s i rl c¡ . r ¡ t l . r c c . r rSr rl e r iS t r i P s h i r r r l o s L r r c s . r f c p l . r . c ! 1 . ( ) h \ i r ) l \ l \ . 1 1 r
l e . l r r r i ( l r r . , l r lb e l r c r l i r n r r c rt lr i l l r . r r r i l l . r r rI f ( ) . c ( l r r c ss u . h . r \ . r \ u l ) ¡ r e n 1 , l l
s u . t i ( , f l i l \ ' ( l ( ) r r \ . ü r ¡ f ) f r ' ( s e . l i 1 )orll sLrIrr'.rIri r ¡i tI l ) l . l r \ \ r r r h
. r.lr r ( l \ .

POS'I'OPHR.A]'IV H,CAITE
l l r c i , r r r r I r c s s i r e b . r r r . l . r g c i s \ \ , , n r j il ,l rl r o r r r s . r r r r lr l r e S r c f i \ r f i t , L l f ( \ \ i r r r j l
-.l.rrs.
l l r e s r . l j ¡ ) r )r l f . r i r r \ . u fr f r r , ^ f , 1 l l l r o L ¡ ' l ¡ , s t o l ¡ c r ' . r t j \ r l \l h r \ u l u 1 1 ,
. t l r l c r t r r ¡ c r l I ' c t l e c n I ' o ' t ¡ i l . e r , r t i rrel , l s I 0 . r n L l I 5 .

---,
260 Con$i.ed Appúachcsand Syrerg¡ti. lrccedures

COMPLICATIONS
In 4 vcars, mofe than 100 peoplc underwent rhc cervicxl fccial lift described
p¡eviousl,\.No postoperativehenatomir requiring a stÍgical rcvision h¡s been
obscrvcd. Two paticnts developcd neu(opmxia. ()ne caseof ncuro¡rraxia ir
volved the m¡¡ginirl branch olthe flcial ¡crvc, uoilaterally afltcting thc krwer
lip. This w:rs ¡rrobably caueci by a purse-string suture th:lt was placeci too
high. Both casesrcvrived complctcly af'terl5 dal,srvithout sc<1uclac.

48 hourspostoperative¡y
Neuropraxia

Theneuropra(
a fuly resolved¡ ressthan15d¿ys.
 'l
h. A.úo¡il. lli\is ol l'hñs¡r sns|elr¡i 26r

()nc p:rticnthed en inll¡nrnr.rforvrc¡ction 6 nronthsl)osfoperirllveh'to.1 non

rcsorl).rl)le
sLriLrreuscclfor plirtvsn;rsrrsperrsion,
N hich \'!rs fer¡(\'cd undef lo
cirlrnesthcsi¡.llenror¡l ofthe sutLrr'c h¡d no delete ous elltct on thc rcsr¡ltof
the ccrvicofirci.rl
lifting.

CASB EXAMPLES
Detcr.rlriningthc Critcria for ¡ Youthful Nech
'lhc
cfircfiil ti¡ ¡ youthtirl nccl<h¡r'c L'ecntlcscribctlbv Fillcrtbogcrt. Wc lriwc
¿ scorcf() c¡ch citefi(nr ¡s lirlIrrysto oLrt¡i¡ i] t()f¡l
.rttr-il¡Lrtcd ()i l0I)()irrs:
l. lhc fcdclinifi{)¡rot tlre i¡fcriol nl¡¡tlibLrliubordcr (,1l'loi¡rts)
2. A str¡rnhyoirlconc.rli¡, (l ¡roint)
3. A visiLrlc¡hvroiLlcirfil¡gc ( I poinl )
.1. l hc ¡cdclinitiont)t thc ¡r)tcfi()fb{)fder'()fthcstcrrr()clcicl(nr¡\l()ici nrL.,
( 2
clc p()ints)
5. A ccrvicorrrcrt¡li]lrlilcL)et\\'ccr105 ¡ncl l2() dcgrecs121)oints)

l'hc resultser-ccc¡rsitlcrctl to Lrcrrr1,¿ool ifthc tot:rl scorc is cquel to or higLr

c r l h r n ¡ l , J / r r l i l ' i t i s e q u r l t o 7 , . r n c ¡l r o r i l ' i t i s l c s st h , r n7 .

-E- '_'_
262 and Sy¡e.gisricProccdLrrcs
Coñbincd Approaches

AestheticAnnlvsis
This ó3-year-oldwoman presentedfor ccrvicofacialrejuvenatiou.Shc had no
surgicalhistory.The definition of her infcrior mandibula¡bordcr was¿bsent
and the anterior bo¡der of her sternocleidomastoid musclewas not visiblc.
Her submental,submandibular,carotid, and omot¡achealtrianglescould no
longerbc scen,Shehad anteriorplatysmalbandsand her thyroid cartilagcwas
not visible,

The surgcrywasperformedunder gcncralanesthesia with one day'shospitcl

staybecauseofthe blcpharoplasty
and lipofilling.

Nonwrgical Plan
The treatmentconsistedof:
. Preop€rative
botulinum toxin injectionsin the platysma

Sargioal Plan
Thc rcatmcnt coruistcdof:
. A MACS-lift for thc middle third of the facc
o Cervicalüftingby platysma suspension
¡ Colcmanlipofillingofthc nasolabial foldsandlips
. Uppcrandlowcrblepharoplasty

Postopeffitive Restalts
Thc paticnt's I -yearpostoperativcresultis determincdto be¿oodwith a scorc
of 8. Notc the good definition of thc submandibular,carotid, and subme¡rtal
regions,and ofthe sternocleidomastiod muscleand the omoclavicularregion.
llr( .\¡.ú(¡iri. U.r¡ (t l'lii\\¡rr Sr!|. r\ni r 263
26+ CombinedApproichcsand Sy¡e$isti. P().edures

Ae*betic Analysis
This 68-year-oldwomanpresentedfor ñcial rcjuvenation.Shehad undergone
a ccrvicofaciallift 10 yearsbefore,and a lip augmentationwith a resorbable
filler had beenperformedelsewhcre.Thc clinicallistory wasother\..iseu¡re'
markable.The defrnitionofhcr inferiormandibularbolder wasabsentand thc
definition of hcr submental,submandibular,and omot¡achcaltriangleswas
poor. Hcr subhyoiddepression wasnot visible.The markilgs were madepre-
opcrativclyon black-and-whitephotographsto cxplail the treatmentto the
paticrrtand to enhanceher understandingofthc surgicalplan and the scarsto
oc cxpccreq.

The surgcrywasperfbrmedunder generalalesthesiawith onc day'shospital

stav.

Nonsurgical Plan
The treatmentconsistedofr
. Preoperative
botulinum toxil injcctionsin the platysma

Sargical Plan
The treatmentconsistedof:
. A MACS-üft for the micldlethird of the fhce
¡ A cervicalIift vir platysmasuspension

PostoperativeResuhs
Thc l-ycar postopclative result is determined to 6e good wldn a scorc of 8.
Notc thc good definition ofthe neck, the oval shapcofthc face, and the defi
nition of thc diff'erent cervical regioru (sLrbncDtnl,submandibular, clroticl,
omoclaviculirr,ard sternocleiclonrastoid ).
r U N U ¡ J \ nr\ü \ \ r r J l o s \ r } t r t r u , ¡ r ú \ ' n l l
266 CombinedAppro¡chesand SyncrskricPrerdúrcs

Aexhetic Analysis
This ól-year-old woman presentedfor facialrejuvenation.Shc had no prevl-
ous surgcriesand her clinicalhistorywasunremarkable. The dcñnition ofher
infe¡ior mandibularbordcr; subrnental,submandibular,and omorrachcalrn-
a¡rglcs;stcrnocleidomastoid a¡eaand anterior border; and sternomandibular
trough wasabsent.Thc markingsweremadepreoperatively on black-and-whitc
photographsto explainthe üeatment to the paticnt and to enhanceher u¡r
derstandingofthc surgicalplal and thc scarsto bc cxpected.

The surgerywasperfbrÍncdunder gcneralanesthcsia

with onc day'shospital
stav.

Nonsargical PIan
The t¡eatmentconsistedof:
. PreopcEtivc botulinum toxin injcctions in thc platysma

Surgiaal Plan
Thc teatmcnt consistcdof
. A MACSlift ficr üe middle third of the face
. Ccrücal lifting by platysmasuspcnsion
. Rcscctionofthe suprahyoidplatysmalbands
. Rescctionofthe earlobes
. Coleman lipofrlling of thc nasolabialfolds and lips
o Uppcr and lowcr blcpharoplasry

PostoperntipeResrla
The I yerr postoperative rcsultis determinedto be¿oorlwith l scoreof8. Wc
obtaineda good rcsult in thc oval shapcofthe faccand the infcrior portion of
the [ecl(, but there is pcrsistenceor rcappear¡nccof a minor suprahyoid
platysmalband in the right sLrbmental rcgion, probablycausedby an insuffi-
cient resectionofthc right platysmalband.
 I l i r , \ i r . ú L i¡ i . lltrn!iL l'1.ú \¡rr S( \rrbi.n 267

ffi
264 CombincdApproaches
endSyn€rgistic
Procedures

CONCLUSION
Presend¡ the platysmasuspensionwith platysmaperyis our basictechnique
for neck lifting. After havingpublishedour seriesand afte¡ the discussionby
Feldman,we conductednew anatomicstr¡diesthat allowedus to demonstrate
that the platysmasuspension fixedto Loré'sfasciain factco¡¡espondswith pli
cation ofthe auriculoplatysmal ligamentdescribedby Furnas.

Sutgical Peat'ls
. The anatomicprilciples underlyingplatysmasuspension havebeenelu-
cidated in basic researchinvolving anatomicdissections.Thcsc have
demonstratedthat the gliding planesaredifferentfor eachregion ofthe
face and neck and affect repositioningof the platysma-skincomplex,
and that underminingthe platysmainducesan infe¡ior ¡edefuritionof
the mandibularborder and sternocleidomastoid musclewith no reposi-
tioning of the submandibulargland.
. The key point ofplatysmasuspension is (l) checkedpreopcmtivclya¡d
confirmedintraoperatively with a hook, (2) morc inferior thar antc¡ic,r)
(3) fixcd to Loré'sfascia,which is not dissected, and (4) reinforccdwith
a nonresorbable ¡unning sutureplacedbetweetlthc fasciaofthc stcrno-
cleidomastoidmuscleand the parotid fascia.
. Platysmasuspension with platysmapexy correspondsto plicationof thc
auriculoplatysmal ligamentof Furnas,
. Platysmasuspension aloneallows¡edrapingofall rcgionsofthc ¡rcckin
the majority of cas€s;however,it doesn'tobviatethc rreedfor aucillary
proceduresin the submentalregion ofcertain very damagednecks(fbr
exanple,liposuction,subplatysmal fat resection,and resectiotrofsupm-
hyoid platysrnalbands).

ACKNOWLEDGMENT
We rvould like to úark ProfessorEphrcm Salaméand Mr. Elissátdeof the Laboratoire
d'Amtomie, Cert¡e Hospitalicr Universitairede Caen,France.

BIBLIOGRAPHY
AscherB, RossiB. Botr inum toxin and wrinkles:¡ew side effectsard effectivccoml¡in
ing proc€dureswidr other treatments.Ann Chir PlastEsthet 49:537-552, 2004.
ElleDbog & firlin ry VisLraL criteriafor successin restoring dre youdrful ncck. Plast
RcconstrSürg 6ó:82ó-837, 1980.
FeldmanlJ. Neck Lift. St Louis: Quality Medical lublishing, 200ó.
Feldman lt. Platysr¡¿suspensionand platysmaplastyduring neck lifti A¡atomical stlrdy
and analysisof30 cases.PlastReconstrSurg 1172008 2010,2006.
 Thc Anatomic Basisof Pl¡gsma Suspension 269

Fogli A, JonesBM, Hindcrer U, et al. [Facclifts complications]Ann Chir PlastEsthet49:

50 563,2004.
¡urnasDW. The retainingligaments ofthe cheek.PlastReconst¡Surg83:ll-ló, 1989.
Grdetto A, DabernigJ, RainerC, et al. Doesa superficial musculoaponeurotic system
existin the faceand neckfAnatomicalsnrdyby the tissueplastinationtechnique.Plast
R€constrSu€ I 11róó4"672,2003,
GrimberteauJC, Scnnrcq-Rigall J,lanconi B, ct al. llntroductionto the knowledgeof
subcutaneous slidingsystemin humanslAnnChir PlasrEsthet50:19-34,2005.
Gu)'uron B, Wattins !, Totonchi A. Modified temporalincision lo¡ facial¡hytidectomy:
An 18 yearexperience, PlastReconstrSurg1I5ró09-óló; discussion ó17-619.2005.
Har-ShaiY, Bodter S\ Egozy-coláDD, ct al. Viscoelastic propertiesof the superfrcial
musculoeponeurotic systcn (SMAS):A hicfoscopicaDdmechánical study,Aesthet
I'¡sr SurA21219 -224| 1997,
IGne MAC. The functionalanatomyof thc lowcr hce as it appliesto rejuvenation via
chemodenervation. FacialPlastSurg21r55-ó4,2005.
KaneMAC. Non-surgical t¡eatmentofplatysmalb¡ndswith injectionofbotulinum tox-
in A. PlastReconstrSurgl03ró5ó-óó3,1999,
lábbé D, FrancoRG, Nicolasr. Pl¡tysm¡suspc¡sio¡a¡d platysrnapcxie duringnecklift:
Anatomicalstudyand analysis of 30 c¡scs,flast l{cconstrSurg 117:2001-2007. dis-
cussion2008-2010,200ó.
Mitz V, Peyron¡e M. The superficial musculo-aponeurotic systcm(SMAS)in thc parotid
andcheekarea.PlastReconstrSurg58:80-88,197ó.
Rouvi¿reH, DelmasA. Anatomichumaine.Tomc l. Tétcct cou. Masson,2002.
TonnardP,Verpaele A, MonstreyS, ct al. Minimalaccess cr¡n¡alsuspens¡on l¡ft: A mod¡'
fi€dSiift. PlastRcconsuSurg109:2074-208ó, 2002.
Treps¿tF. FáccIilis ofthc mal¡r,jug¡l andnásol¡bialarc¡.A¡n Chir PlastEsthet39:597-
622,1994.
TemporalLift
by Fasciapexy
272 CombincdApproehcs and Syncrgisti<Procedüres

\IT
Y Vhen perforning a full facelift, one often noticesan insufEcientimprove-
ment at t¡e levelofthe temporaland malarregions.This represeltsa t¡ansito-
ry zone between the forehead and the face.Thc temporal lift with fasciaplasty
ameliorates t}teseproblcmsby usingan intracapillarytemporalapproachto el-
evatethe tail of the b¡ow and improve üe crow's-feetand malar a¡ea.The
temporallift is accomplished by suturingthe previouslyfreedtemporoparietal
fasciato the temporalfascia.An associated skin resectionofthe lower lid is also
used.

PRTNCIPLES
Thc conceptoffasciapexyis fundamentallydiffercnt Íiom that ofsubperiostcal
techniquesthat lift all of the tissuesen bloc. The logic of this techniquc is
bascdon thc facttl¡at thc ptosisofthe brow tail is cutancous.Thus this proce-
dure is guided by three principles:
l. Skin redraping
2. Solid anchoring
3. Preservation ofthe hairlinc

I do not think that subperiostealdissectionis indicatcd for cutaneousim-

provement.Othcr techniqueshaveprecariousanchoringmethodsor movethe
hairlinctoo far back.This techniqucprevcntsthe illogicallift ofthc facialskin
toward the temporalrcgion. Thc improveddraping guaranteesmore natural
resultsand offersan exccllcntmcthod to avoidround eyes,This techniquccan
complementa foreheadlift and facelift. It is usuallyperformedwith an upper
and lower blepharoplasryA canthopcxyor canthoplastyis rrot required,ex-
cept for a specincindication.
 Tcmpof¿l üft by Fásci¡pcxy

GOAI.S
Improvement ofthc clinical signsoftcmponl aging is thc primary objective of

Specificgoalsincludethe follo$¡ing:
l. Elcvationof thc tail ofthe bror,
2. Correction of crow's-fcct
3. Redrapingof mala¡skin to addrcsstemporaland malarwrinkling
4. Grcatc¡ skin ¡esectionof thc lower üd to co¡rcct wrinkling

ANATOMIC CONSIDBRATIONS
Thc tcmporoparictal fasciareprcscntsüc lateral extension ofthc galca and s
somctimesdescribedasthe galca.Anatomically spcaking,the galcacnds at thc
level of the temporal c¡est aud what we callgolao is acually the tcmporopari-
eta.lfascia.That explainsthe tide ofthc first article I pubüshcd on thc subjcct:
"Tcmporal Lift by Galcapcxy."

The galca is adjaccnt to the superficial tcmporal fasciaand the pcriosteum of

thc frontal bonc. Thcse tlrce sfucturcs are confluent in a 5 to ó mm band lo-
cated in the mcdial part of dre temporal bone crest and arc adhercnt to thc
ocriosteum and tie bone.
27+ CombincdApproachcs
ddSynergisticProccdúres

Dependingon the obliquity of the temporalcrest,the tail of the brow will

measu¡eftom one third (left) to one qtarter (right) of the total length of the
brow. The brow tail is not under the irrflue[ceofthe ftontal muscle,which is
an elevator.Its ptosisis only influencedby dre depressors,suchasthe orbicu-
larisoculi muscle,

The temporalbranchofthe facialnerveis locatedbeween I and 1.5 cm in tire

horizontalprojectior of the brow and there is a deepbranchof thc supraor-
bital nerveinnervatingthe frontotemporalscalpas describedby IGize. Tlus
branchis locatedbetweetrthe deepleafletofthe galeaand the periosteumand
runs betweenthe orbital rim and the inferiorpart ofthe temporalc¡est.

Subperiosteal detachmentexte¡dsto the orbi-

tal rim (blue line) without danger to dre tcm-
poral branchof the facialnerve and the sen-
sitive branch running from the supraorbital
nerve.
 Tcmponl Lift by Fei¡p.ry 275

Lirnits of the Sugical Area

Thc surgicalareaon which this techniqucfocusesdoesnot correspondto the

arcadescribedby anatomists.It is limitcd by the following landmarks:
L The temporalcrestabove
2. The scalpincisionposteriorlyand parallclto the hairlinc
3. Thc zygomaticarchand the malarbone below
4. The orbital rim antcriorly

Planes of Dissection
The subfascial plane. Disscction ofthis planc allows the frecing ofthe differ-
ent musculoaponcuroticattachmcntsfrom the temporal crest üthout any risk
of nervc damagc, This will cnhancc thc lift of the tail of the brow. This easy
dissectionwill not risk atrydamageto hair folliclesand canbe carriedout up to
I cm in ftont ofthe hairline. Thc incision ofthe temporoparictal fasciais made
under direct vision to allow us to grab and raise the flap and also to change
plancseasilyiffurthcr subcutaneousdisscctionis ncccssa¡y,

Thc subcutaneous disse¡tion plane. A soft, meticulous dissccrion in this

planepreventsdamageto the temporalbranchesofthe facialnerveand allows
us to separatethc orbital fibcrs ofthe orbicula¡is muscle from thc skin.
 Combined ApproachesaDdSyne¡gisdc¡¡ocedures

ADVANTAGES
This temporal lift with fasciaperl'can be used alone o¡ in combination with an
extensivelift and will accomplishthe following:
. Managementofcutaneousptosis(the loweringofthe brow tail, tempo
ral, malar, and inferior üd wrinkling)
. Solid anchoringthat relieson the temporoparietal fascia
. P¡eventionofhair loss
. Preventionof backwarddisplacement ofthe hairline

This techniqueis efHcient,reproducible,relativelyeasyto perform, and hasa

low incidenceof complicationsif meticulouslyexecuted.

INDICATIONS AND CONTRAINDICATIONS

This temporallift techniqueis indicatedfor a patientwho presentswidr late¡-
al brow ptosiswith a short distancebeween the eyelashes and eyebrows.It rs
also appropdatefor a patient with a late¡al extendeddermatochalasis with
crow's-feet,which canbe removedwithotrt the dangerofa round eye,or witlr
a combinatio¡ of theseproblems.

Becausethe temporalregion hasits own unique requireme[ts,this technique

is particdarly applicablefor addressingproblcmsin this area.It can be used
alonein a youngerpatientwith or without periorbitalagingwho hasno signif-
folds or jowling.
icant ¡rasolabial

This techniqueis contraindicatedwhen the cntire brow is ptotic or when it is

locatedtoo low. In suchcases,a forcheadlift by a coronalor endoscopicap-
proachcanbe done.The temporallift is not a treatmentlbr lagophthalmosor
ectropion.

OPERATI,IE TECHNIQUB

KeyElemants
. Speci6cÍeatment ofthe temporalarea,which is a transitoryzore be-
tween face and forehead
. Separateincision
. No surgical migration of the facial ski[ into the temporal area
¡ Avoidsa lateralextensionofthe scarduring an upper or lower bleph
aroplasty

-
 Tcmponl Uft by Fasciáp€xy

Markings

While palpating t¡€ tcmporal atea, I mark the temporal crest (dotted,linü,
Within the hairline,a 3 to 4 cm straight-linescalpiniision lcontinuorsline) is
markedpcrpendicularto the temporalcrestand parallclto thc hai¡üne.This
line is locarcd 3 to 4 cm behind thc hairline, dcpending on hair dcnsity.

A second 3 to 4 cm parallcl line is d¡awn I cm in front ofthe hairline. This s

the levelof thc temporoparietalfascialincisionthat dete¡minesthe extcnt of
the subgalcaldissection.The subcutaneous disscctioncould extend as fa¡ as
the orbital rim, the rygomatic arch, thc malar bone, and the infcrior pa.lpcbral
a¡ea.The areasofundcrmining aredclineatedasfbllorps:
l. Subpcriostcal undermining
2. Subgalealundermining
3. Subcutaneous undermining
274 Conrbi¡edAppro¡chesand Synergisric
f óccdürcs

Incisions
The intracapillary incisio¡ is made with a No. 15 bladc. Subperiostealdetach-
ment, following a I cm periosteal incision, is caÍied out at the level ofthe
tempor.rlcrest.rsfir ¡\ thc orb¡tll rim.

Dissection
The subiiscialdissectionis easilycarriedout to thc sccondlirredescril¡edear-
lier.With the sameblunt-tippedcurvedscissors u[dcrncarh rhe skin, the tenr-
poroparietallirsciais opened4 cm at thc lo,el ofthe secold line.

The temporoparictalfasciai¡rcisio¡ris madein liont ofthe hairlineald parallcl

to it. He¡rostasisis established
u¡rderdilect visionwith the elcctricscalpelald
useofa cold ligl¡t letr¿ctor.

With tractionol the frccd tcmporoparietal firscia,the mobilizationofthc brow

tail is evaluated.Then, with traction on the remporalregunleürs,thc mobili-
zation ofthe skir ofthe malarareaand the lower lid is alsoevaluated.

This maneuveris repeatedat three differert levclson thc galeawhere the

stitcheswill evelltuellybc located,dependingon what is needed.The subcute
neousdisscctiol can be extendedas hemostasisis established.Thc surgcon
¡1ustbc aw¡r'eofthe f¡rcialne¡velocatedat this plalle.
 'linrrrrl
l . i 1 ih \ l i s c i v r \ \ 279

t/
,'^l ==-

Oncc thc ccphirlictcrrpon)Pirdct¡lfitsciiris in rhc clcsirctlposirion,ir is lircrl

l itlr .r briridetl Ll tlpc stitch t() rhe tcnr¡rorirllponeurosis. l hc dir.cctiol ofthc
slltL¡fcis p¡rxllcl ft) thc scillpincisionto ar()icltc¡ritrgi.lhc clist¡nccLren|ccn
thc ccl)hirlic¡n(i cirlrclirl crlgcsof rhc g¡lci] rcprcscltsthc clcvirtioni¡sdcnt(nl
strillccl i¡L)ovc.Ncxt, t\o n(uc stitchcs ¡rc ¡r¡tlc.

Bclolc sutr.rring,orrcc¡n disscct¡rsmuch ¿srcqLrircdin tlrc srrperior.sLrlrfiscial

spicc t{) irvoid uúsi!¡htlv plcirring th¿t ryoukl fcqLlire 2 t() 3 p()sfT)errtivc
n)()nthsl() dis.rpl)c¡r.
280 (innbnrc.l Attn)r.hcs ¡nd Syncrgisri.P.o.cdurc\

At thc cncl, thc cxccssskin tiom tl'rc lorvcr lici cl¡r trc dilcctly excisccinsing thc
\!'ith()utilny rcsccti()nofthc fibcrsofthc orbicuhrisoculi nrusclc.
sciss()rs

Suture Placement

Suturing the sc¿lpis doDc lvithont tcnsion irnclwithoLrtrcscctiot. Wc lrsc.r

reso¡t¡¿blc 3-0 Monocrvl. For the lotr'crlir'I,rvc Lrsce ltLuDbcrl'0 int¡¡tlernis
Ilcxocrin that is r.e¡novecl3 davs latcr, elong rvirh sutLtfesofthe potentiirl up-
pcr trlcphrro¡rllsn'. No c1r¡insarc usccL
 Tempoól üft by Fsiap€rf 281

POSTOPBRATIVE CARB
To reduccedemaand bruising,I alwaysapplyice o[ thc tempo¡alareafor a
few hours.The ice is kept in placcwith a dressingthat is ¡emovedthat eve-
ning. There will be more edemaa¡rdbruisingin thc lower lid and at timesin
the malarareawher therehasbccDextensivcsubcutaneous dissection(needeo
in approximately15%ofcascs).

RESULTS
To assess the resultsof this temporallift, we ¡cvicwedthe chartsof 572 pa-
tientswho wereoperatedon betweenJune199ó and fanuary2005. The aver-
ágeagewas50 yearsold. Four hundredtwenty p¡tienrsbenefitedftom a full
facelift (frontal,facial,and cervical),and 20 patientshad an isolatedtemporal
lift. An associatcdupperblepharoplasty wasdone in 452 cases,and in 188 cas-
es lowcr eyelid herniatedfht padswcre removedvia a transconjuncrival ap-
proach.Finall¡ a lowcr eyclidskin resectionwasdone fbllowing a fisciaperyin
521 cases.

The resultsofthis tcchnique,with a l0-year follow-up fbr the first c¡sesand

l-year follow-up for the lastpaticnts,areevaluatedaccordingto thrce crirena:
l. The distancebetweenrhc cyelashes and thc rail ofthe brow
2. Improvcmentofcrow's-fcetratedon a scalef'¡omto I ¡o 3
3. Improvemcntofwrinkles ofthc lowcr lid and tlrc malarlid ratcd on a
scaleof I to 3

Of572 patients,525 had a good to vcry good result,25 had an averageresult

and 22 had,an unsatisfactoryresult. Unsatisfacto¡yrcsults were primarily
causedby impropercorrcctionofthc tail ofthc brow. Now we haveimproved
our result¡üth a subperiosteal
dctachmcntofthe temporalcrcstand the lar-
clal part ofthc orbital rim.

In my hands,this techniqueappearsto bc more efficientthan thc fásciaplica-

tion describcdby Hamas.As I perforn thc incisionofthc temporoparietal fas-
cia, I alwaysnotice a spreadingofthe two edgeswitlr a relativelyflxed caudal
flap and a cephalicflap that can easilybc brought up, Alchorilg on a solid
 f
2 {J2 Cdnbi¡crl ]\rpu.l,cs ¡nd S\ncrgiri. lr¡rcdrrs

stlLlctulcsuch as thc fenrpof¡l flsciit*ill guarantccits ¡rcrsistcnce.lvloreovcr,

thcrc is oo blckrr'lrclclisplaccncntof thc hairline,es melrtioncdbv Flarnes.
This nrlrrcu,,er'brings ebout ¿ tmc \\'¡\'elikenrovenrcntth¡t rvill ¡raintain irs
position.rsthc sLrbjaccnt tissucs:rrcbroLlghtLlp.Ily Lrsine!
cDdoscopyI ur ablc
fo ¡\'oic1thc long sclr ofthc cruonelliit, the tenrpolll branchesofthc ficc lili
¡¡rd, ¡llostof dl, c\ccssivesc¡lp Íesccoon.

Thc nrost clevcr'l¡, ¡rcrfbrmccltcmporel lifi inevitiblv rcsultsin scirls,cr.cn if

thclc is n() tcnporil ¡lopccia.I prcf¡r the 4 cnr incisiontlrit illo\vs r¡scofthc
c()ld lisht rctrilctor,ilthoug,h I collld n)rnrUlewithout it. lt is ir tiruc sar.ing
proccd(¡rc,¡11(lthcrc is n() hilir lossiurd no tcrrsiontltit c()r¡ldcausctlopcci]
rvhc¡ thc incisionofthe l'irsci¡is ln¡clc iu fio¡t ofor p()stcriott() thc h:rirline.
Thc dilli:rcntplirrrcs oftlissccti<¡n
allorv¡n:rnrtonricrlpprotclrirrd hcl¡rto ntan
¡!¡c wdrrklirrqin thc tc¡rporrrntlllr trclr, bLlt this tcchniq c (l()csn()t t()tilttv
rcsulrsirrouI sc|ics,thc ti1il()fthc
lrcrf rhc InirlilrLl¡qs.I11thc iiw unsxrisf¡ct<¡_t'
l)r(^\'\\'¡s in¡(lcquiltclvlif_tcd.

()¡ ¡hc o¡hcr hend, tlrc irrrplot'cntcn¡is spc(tirculrrin thc rcrlporonrirlirrrc

gi()n. \\'hcrcthc finc ¡issLlcscrhibi¡ linc rvrinklcs,rtncl.l! rhc l(^vcr li(1,\,ltcfc
onc c.rrrrcscctir st|i¡Tofrv¡inl<lcrlskin $ith inrpLrnitl.It is ¡n crccllcnr nrcrhod
lrrl prcvcntirrg¡ncl sontcrintcsc()rrccrin!i:rrounrl c1,c,¡nd thclc will Lrcll<r
Dccdlirr-rrdjunctivc chcnricdlIccl thclapv or lescrrcsurtiicinu.

COMPLICATIONS
In or¡r'scricsfi!,c !¡oilitcrdl hcl¡¡t<¡ntirsocculrcrl; rhcsc wcrc tlr'¡incd L¡llclcr-
locel encsthcsi¡.Thcsc c¿scsl,crc fi<¡lt thc lirst 30 ptticnts in this scfics.All
ot thcschcnrirt()nrils rcsultcdfionr bltxrrl cliflirsit¡r,irnclno hcnroslirsis t,irs ru
qLrirccllirlIrrlirrg thescclscs.I xrrv ir¡rplt,icc lin'sclcf¡i hotrrs,irnrl I hlvc nr¡t
h¡d ir hcDirtom¡ sinco.F()Ltrcirscs()l trilnsicntllo¡recil $,crc sccn Nhc¡l fhc
tcnr¡rt>r'<4r.rrictel
fisciirincisiortl'irs ¡rcrfirrntcdunrlcrthc scllp. l'rr¡ntI hc tl cll
ticth c¡sc ()n\\'.rrd,thc firsciirl
ircision \\i¡srr¡dc i1tlc.rsrI cn¡ or mr¡c in ll'o¡tr
ofthc hlirlinc, lncl no irlopcciirhirs bcen r-c¡ror tcrl sincc.Althorrgh no per'
m¡ncnt piurl\¡sisol'thc tcl¡pof¡l l¡r-¡ncflofthc iirci¡l ncr'"c \v¡s sccn, ciliht
pirticntsh¡d \\'cirkncss of thc fl-(nl¡lis ¡lLrsclcthdt l¡stcclfion 3 rvcclistr¡
2 no¡rths. Llnlikc othcr cornplicittions, thcsc\\'crcsccltin rccctrtc¡scs¡ltcl cer
t¡inlv occurrcdbcclLrscr¡f ntorc lirpid clisscction enri cxccssivc stfcfchil!!.
 ,rL I r I I \ I ¡J.¡

CASE EXAMPLES
Atstbetic Analysis
l h i s . 3 1 r c . r r o l t l l o n ¡ ¡ l t I r - c s c n t e J¡ j t h l . ¡ c l ¡ l l r r ' ¡ ¡ l ] r t o s i s\ i 1 h ( ) L t rc \ . e , .
'l
s l ( i r rr ¡ t h c l c r c l o 1 l l r c u 1 r ¡ e l l i c l h c r c r r c l c n o l . r t 1 l . r t l rh, L r rr h c s l i i no l t h c
l ¡ ¡ r c l l i i l s r . r s l i g h t l v r r l i n l < l c d . l h c p . r r i c n rl ¡ ¡ r ¡ k c rsi , ¡ i . r n ( li r r c \ | r c \ s i \ c

Srn'gicnl PIat
'lhc
t r c i l l n r c u lr ¡ ) n s i s f f ((l ) l i
. ,-\ tcmp()r.rl littlith rcnr¡oloP.rrict.rltisci.rpcrr ro rhc sLrPer.liei.rl
tr tll1rorrl).tPonctttosis
. '\ lolcl crclid
Iineh L¡lcPir.uo|l.rstv

I'ostoperatirc llesults
I l r c r c s L l l t s . u c s l t o l n 6 r t r r , r t J t s ¡ o s r o ¡ c r . l i \ c l \ .I l r e ¡ i \ l . l ) . e l ¡ r t l e , , n t h c l ¡ . r
ticnt'scrcl.rrhcs.rrrb r ll o r r l t r s L r c c ni l c r ' c . r s c r S l . l r c J t . t s . rl t , r l r ¡ r i c r . ( \ l ) f c \ \ i ( ) n .
I l r e r e t l ¡ . r P i no, rl t l r i n r . r l . l . l c . t . l l . l l ¡ ¡ r c r ' l i i l s l i n ¡ r c l n t i t r e ,lll r r r c n ) ( , \ . t{l ) l . l
( ) l
l h i r r s l f r l ) s l i i r rr i t l r o L l t t l t c r l . t r r r r c r ' rriol r ¡ r i l c v c s .

+
'/i-\

T:
7
244 Combi¡ed Approachcsand S_vDergisric
lroccdufcs

Aesthetic Analtsis
This 52-year-oldwoÍnanpresentedwith moderatebrow ptosis,blepharochal
asis,shorteningofthe distancebetrvecnthe brows and eyelashes.
and round
eyeswith scleralshow.

Surgical Plan
The t¡eatmentconsistedof:
. An upper blepha¡oplasty (preoperativemarkingsofdre skin
excisiona¡e donewhile the elevationofthe lateralpart ofthe
brow is simulated)
. A temporallift with a temporoparietalfasciapery previously
ilcised to the levelof the superficialtemporalaponeuÍosis

PostoparñtiveResalts
The rcsultsare shown 9 months postopemtively. The distancebeween her
cyclashesand browsis increased.Improvementis significant,becauscthe pro-
ccdu¡ccor¡ectcdthe round eyes.No canthopexywasdone.Tl.reupperlid scar
doesnot extendtoo fhr laterallybecauseof thc tcmporallift, which rcdistrio-
uted thc cxtrnorbitnlsldncxccss.
Temporal Lift by Fásciapert,
 246 (bmbincd Approichesand Syne.sisricPrccedurcs

Aesthetic Analysis
This S3-year-oldwoman had narkcd signsof periorbitalaging with crow's-
fect,a moderatedegreeofblcpharochalasis, an upperlid nasalfát pad,and no-
ticcableskin excessat the levelof thc lowcr lid at an equaldistalcc bctwccu
the lower ciliary borderand the orbital rim.

S*rgiaol Plon
Chronologically, the t¡catment consistedof:
. A tcmporal lift to ¡aisethc latcral part of the brow and to redrape
the skin ofthe c¡ow's-feetand thc malarrcgion
. An upper blepharoplastywith resectionof extra skin and of a
strip ofseptalfibe¡softhe o¡bicularisoculi muscleand removal
of nasalfat
¡ A facelift and necklift
. A lower eyelidpinch blcpharoplasty

PottoperÚt;ve ResnlB
Thc rcsults arc shown 14 months postopc¡lrtivcly. The front¡l and obliquc
vicwsshow a natural,stablcrcsult without modificationof hcr look or of thc
hairline.Thc temporaland lid scarsarc not visible.Not€ thc good dcfinition of
thc uppcf lid plcat, corrcctionof thc crow's-fcct,and redrapingof thc m¡lar
lrd lowcr lid skin.Thc poor clualitysLin of thc lowcr lid wasdircctly cxciscd
8 mrrrf'romthc cilia. Onc must not hcsit¡tc to inciscthe skin at this lcvcl;thc
sc¡¡srrc ¡rcvcrvisiblcwith this ou¡liw ofskiu.

-
 rcn,ponl Liii lx iis.i¡fe\1 247

r
H l&
,:
 288 CombinedAppróa.hcsdd Sy¡ergisriclrocedurcs

AeoheticAnallris
In this S9-year-oldwoma¡, the aging processhad signifrcandychalgcd hcr
appcarance. Shehad a smallscleralshow;her brow wasvery high bccauscof
thc permanentconffaction of the lio¡rtalis muscle.This phenomenonis a
compensatoryreactionto blepharochalasis, which impairsthe eyesight.She
had modcratefat bagsand fine rhytidsin the lower eyelids.

SattgicalPlnn
Thc trcatmcnt consistcdof:
¡ A combined approachto the lower lid: at the beginning of the
operation, a transconjunctival approachwasused that permits
very moderate¡cmovaloffat bag;at the cnd ofthe operation,
a pinch blepharoplasty wasdone
. Ari upper blepharoplasty widr resectionof the skin and orbicularis
oculi muscleand removalof nasalfat (dre markingofthc skin
excisionis donc while elevationofthe latcralpart ofthe brow is
simulated)
. A tcmporal lift with a latcral uaction to give a horizontal direction
to the brows and to rcdrapc thc skin ofthe lower lid
o A face lift and ncck lift by skin and platysmamuscle anchoring
(SPMA)

PostoperntiveResal*
The resultsare shown 18 months postoperativcly. Thc paticnt looks mc¡re
scrcne.The positionofthe browsis more harmonious.The distanccbetwecn
cyelashcs and brows is reduced.Thc improvcmcntis very significantbccausc
of the proccdure that correctedthe rould eycs.No canthopexyhas bccn
dore. The rcscctionof the cxtra ski¡¡without tcnsion on the ciliary bordcr
nlust be doDeat drc cnd ofthe proccdure.Indced, the temporallift and tlrc
facelift bring more skin at thc lcvcl ofthe lower lid. On tic profile view,thc
uppcr lid is well defi¡ed and rhe look is more clear.

--
 lcrrpo il l-iti b\ f.s.¡pc\\ 249

i i
L'
lIr
t
,\

"íG'

I
Co¡rbnredApprodchcs¡nd Sl,úcrgisti.P,1)ccdurcs

Ae*betic Analysis
This 49-year-old wonan rvantcd to look ¡cfrcshed and lesstired. The shapeof
hcr l¡roq's and the distince betwcen thc cyclashcsand brou,su'ere correct, but
the excessofskin ofthe upper lids was significant, asymmetrical,ancl extenclcd
lirr laterally.Thc wrinklcs ofthe crorv's-f'eetu'ere tleep and visible. Shc had filc
rhvtids and no fit traesin the lower evelids.

SwrgicalPlan
The tre¡tment consistedof:
. A temporallift with lateraltractionto redrapethe skin ofthc
tcmporalareaafterfieeingthe skin from thc orbital fibcrsof
thc orbicularisoculi muscleand to exert¡t tensionon the lower
lid skin
. An rpper blepharoplasty with rcscctionof sldnand a strip of
orbicularisoculi musclcand rcmov¡l ofnasrl firt. As usual,thc
markingof tl'rcskin excisionis cloncwhilc tltc clcvationof'rhc
latcralpart ofthe brow is si¡lr¡lated.A complcmcltarytrianglr-
lar ¡cscctionofthe orbital fibe¡softhc orbicularismusclcis
performedlaterallyto weakel thc nrusclccontractiol'I.
. A pinch skin rcscctionat thc cnd ofthc opcration

Postopera,ti,ve Reswlts
Thc rcsults¡rc sccn22 nronths¡rostopcr:rtivcly.'fhc ¡raticntno longcr l¡r¡rclrc
'fhc
tired and h¡s l rcstccl irppclrlncc. ¡'rositionof hcr brolvs l¡its ¡tot bcen
¡rrodificd. Bccauscof tl'rc tcmporll lif't ¡ssoci.rtcclwitlt the lirtcr¡l rcsecrior of
orbital fibcrs, thc crow's-f'cct luvc disl¡rpcarecland only r firv finc lnd rltur¡l
rhyticlspcrsistrt thc lcvcl of the lolvcl lid without modificationof hcl look.
-fhe
r.rpperlid is wcll dcsigned. Notc th¡t thc licl sc¡r¡ do not cxtcnd too fiu
laterrllyout ofthc orbitrl rirrr.
TempoEILift byFascüpexy 291
292 conbincd Approaches
¡trd synersis¡icl'rocedu¡es

Aexbetic Analysis
The caseofthis 4l-year-old rlroman was vcry inte¡esting. She looked like hcr
fathe(, u'ith a genetically lolv position ofhcr brow tail lnd blepharochalasrs.
The skin ofthe upper lids lay on the cyclashcsand covered the lateral canthus.
Hcr sight rvasrestricted laterall¡ and the wrinkles of thc crow's feet progres-
sively becirmefolds. Thc eycswcre permanently h.lfclosed. She also cxhibited
considerableskin excessofthc lor¡,c¡ lids without fat pacls.

Surgical Plan
The treat¡rentconsistedo1':
. A temporallift with a strongtensionon the brow tail to clevatc
the lateralpart ofthe brow and redrapethe skin ofthc tcmporal
area,with disappcarance ofthe skin fblds
. An uppe¡ blcpha¡oplasty with largeresectionofskin ard a strip
oforbicularisoculi músclea¡d rcmovalofnasalfat. As usual,the
markingofthe skin excisionwdsdonewhilc thc clcvatior-t ofthe
lateralpart ofthe brow wassimLrlated. A complemcnta¡ytriangu-
lar resectionofthe orbital fibersofthe orbicularisoculi ¡rusclc
wasperformedlaterallyto weakenthe muscleco¡traction.At thc
end ofthe operation,a pinch skinrescctionpermittedremoval
ofa 5 rnm-high skin strip.

Postopera,tie e Re su lt$
Thc rcsultsarc shown20 nonths posto¡rcrativcly. Hcr br()u,s¡rc nor¡,wcll lo-
crtccl;their elevationlbsorbcda part ofthc cxtr¡ skiltofthc tcnlporalarc:t.Thc
paticrt'sirppcar¡nce is grentlyimprovcd,¡nclhcr cycsightis no longcrrcstlictccl.
Notc that, cvcnin this crsc,thc lid scarsclonot extcndtoo fir letcrirlly.
 l . ¡ r . { r I f i L I r { r L. , 293

f
t

'l
his lcahrriqucc¡r lre usc,:1 rs .rr i¡ol.rtc,lploccr:1ulc or in conjrrnction
\ ith .rrr.rssoci.rtcLl tcchni(loc.
No scrlp rcscctionis rcclLrirccl.
'lhc
I c s u l ti s n r r t L r r¡¡ul 1 1t h r f c i , !r r ob . r c k r r . ] |rr1l r ( ) \ c n r r o
r rl t l r cl r . r i r ' l i r c .
294 Combi¡cdApproaches atrd SFersisric P.ocedures

BIBLIOGRA?I{Y
Da¡dourJC, KtorzxrT. Endoscopic decppcriorbitall;fting:Studyxnd resultsbasedon
50 consccuti\rcases. AcstheticPlastSurg24:292-298,2000.
FogliA. Temporalliti by galeapery: A rcviervof270 cascs_ AesrhcticptastSurg27:159-
ró5,2003.
HamasRS,RodrichRt- Prevenrirghairlineclevarionin cndoscopic brow lifis. plastRe-
constrSurg99:1018'1022, 1997.
HestcrTReCodrer MA, Mccord CD. Sr¡bperiosteal malarchecklift wirh lower bleph,
aroplasty. In Mccorc{CD, ed. EyeliciSxrg€ry:I'rinciplcsafld Tcchniques. philadel-
phia:Lippincon-Ravcn, 1995.
IsseNG. Endoscopicfacialrciuvcnilrion:Endoforche¡d,the tunction¡l liÍi. Aestheüc
PlastSurg18:21-29, 1994.
KnizcDM. A studyofrhc supraorbitlrl ncrvc.Plist RcconsrrSurg9ói564-869,1994,
M:rchacD. IPrescrvaiion ofthe h¡irl¡ncin facclilisby doubleremDoraland retroauricu-
l¡r ror¡iionfl.rpslAnn Chir P¡¡5rEsrhcr37:519 -524,1992.
Mccord CD Jr,ShoreJW.Avoidrnccof'complications in lowcrlid blepharop¡asry Oph-
dralmology 90r1039-104ó,1983.
Nahai¡*, EavcsFF, RosnvickJ IIL Forehead lift and glabellarfrown lincs.In Bosrwickt
lII, EavcsF¡*,Nrhai t*, cds.EndoscopicI'lasticSurgery,. St buis: euality Medical
Publishing, 1995.
-l(),
Ps¡llakis JM, Ramlcy Camargos A. Subpcriosieal appro¡cb¡s an inrprovcdconcepr
fbr corrcctionofthc agingfacc.PlastReconsrr Strg 82:383,394,1988.
ll¡mircz OM, Endoscopic iechniqucs in fhci¡lrejuvcnat¡on: An overviewAcstheticplasr
S u r gl 8 : l 4 l ' 1 4 7 ,1 9 9 4 .
 Chn

Combiningthe
MACS-LiftWith the
TemporalLift
AlexisM. Verpaele. PauickL. Tonnard
296 Combined App.oachesaDdSynergisticPro.edures

A
.falthough we havebeengenerallysatisfiedwith the co¡¡ecüonofthe lower
two thirds ofthe faceprovidedby the MACS-Iift, in somepatientsthe result
seemedincompletebecauseof the remainingptosisof the late¡albrow and
temporalregion. The simpleMACS-lift corects the lower third of the face.
This includesthe cervicomentalangleand platysmalbandsby cranialtighten-
ing ofthe platysma,jowls, marionettegrooves,and to somedegreethe down-
ward slalt of the cornersof the mouth. In addition, the midcheekhollow is
correctedby verticalrepositioningofthe lower cheekvolume.

The extendedMACS-lift alsoprovidesan effectivemidfacelift through the

third malarpurse-stfiogsuture.This correctsthe nasolabialfolds,addsvolume
in the zygomaticarea,shortensthe verticalheight of the eyelids,and blends
junction.
the eyelid-cheek

The overalleffect of the MACS-lift craniallyreachesto the intercanthalline

and lifts facialtissuesinto the uppercheekand malarregion.This verticaldrs-
placementof facialtissuescausesan obviousbunching of skin in the lateral
part ofthe lower eyelidand paracanthal region,which needsto be resected.At
the end ofan extendedMACSJift, a pinch blepharoplasty is mandatory,

In manypatients,facialagingis eüdent not only in thc lower wo thirds ofthe

face,but alsoin the upperthird, the b¡ow, and the frontal region.This hastra-
ditionally beenaddressed by a classicbrow lift, which can be carriedout at a
subperiosteal or subgalcallcvcl, or clseat a subcutaneous lcvcl. The lift at the
subpcriostealor subgaleallcvcl hast¡adirionallybcen pcrficrmedthrough an
open bicoronalapproach,or in rcccut yearswith cndoscopictechniques.The
subcutaneous approachnecessitates a prehairlineincision.Thc advantagcs of
thesetraditionaltechniquesare a predictablea¡d consistentoutcome and a
low rate of complicatio$. The disadvantages includelong scars,possiblealo-
pecia,sensorychangeswith thc open bicoronaltccluriquc,and problemswith
the fixation method in dre endoscopictechniquc.Morcover, in a t¡aditional
b¡ow lift t}¡ereis a daogerofovercorrectingthc rnedialpart ofdre brow, often
resultingin an unnatural"astonished"appearance. It is an aestheticmisconcep-
tion to pull üe whole eyebrowupward. Many very attractiveyolrng women
havea remarkablylow positionofthe medialpart of the cyebrow,but an ele-
r¿tedr¡il ofrhe l¡ron.wirh a clear.openparacarthal rcgion.
 Combi¡ing dle MACS,Lift With rhe T€npo¡at r,G 297

The position ofttre eyebrowsin this 27-yea¡-oldmodel is lower mediallythan

laterally.The shapeofthe eyebrowsis not arched,but almosthorizontal
and
sffaight.The paracanthalareais crispand open,with absolutclyno hooding.
294 Combin d Apprc¡chs úd SyncrgisticProccdurcs

In most cases,the most eüdent sign of brow aging is a hooding of the lateral
drird ofdre eyebrow,often combincd with horizontal wrinkles and folds in the
pa¡ac¡nthal ¡egion. To preservcor restorc fácial harmony it is necessaryto in-
clude üis region in the facialrejuvenationsurgery.

It is our conüction that currendy only the late¡al b¡ow needs a surgical cor-
rection becausethe middle thi¡d of the forchead can very easilybe co¡rected
with botulinum toxin injections. In our practice we have seenneedle surgery
by botulinum toxin injections replaceknifc surgcry by endoscopicor open fore-
headlifts. Sincethe introduction of botulinum toxin ása very eleganttreat-
ment modalityfor glabellarand frontal grooves,there hasbeena clearshift in
the indicationsfor brow lift toward a pure temporallift.

There arethree issuesin temporallifting:

l To avoiddamagingthe ftontal branch
2. To avoidaltcringüe positionofthc hairline
3. To obtain a good and stablcresult

Mytiad techniqucsexist that usca subperiosteal,subgaleal,or subcutaneousdis-

sectionplane,or a combinationofthcse.Thc tcchniqueofAlain Fogli allowcd
us to continueworking in a simplc way,without worrfng about thc frontal
branch,and with rcmarkablystablclong-tcrm rcsults.

As we gainedcxpcricncc,we further simplifiedhis technique,limiting the dis-

scctionto the subgalealand subcutancous plancs,omitting the subpcdostcal
part ofthe surger¡ We alsomodificd thc oricntationofthe incisionto a more
horizontal di¡ection to bettcr deal üth thc paracanthaland temporal skin ex-
cesscreatedby the vcrticallifting in thc extcndcdMACSlift.
 Conrbiniogd1eMACS-Lili With the Tcmpo¡d Lift

INDICATIONS AND CONTRAINDICATIONS

Follorvingare nvo major ildiciltions ti)r a temporil bro\\,lift:
l. Preexistingtcmporalhooding or ptosisofthe t¡il ofthe cyebrow This
consistsofhorizontal foldsin the ¡Tuacanthal rcgion cxtendinginto tlre
tcmporalarea.Thc tcmptationto coÍcct this with an uppcr blepharo-
plastvis great but absolutcl,vs,roltg, becausethis rvoulclinsteaclprrll
dorvlt tl,c eycbrorvtail, counteractingthe clcsiredrcjuvenation.
2. The ¡rleclictcdlikelihoodthit asa rcsultofa siguificantverticalliftirg, a
g.rthcrirrgof skir in the tempoml rcgion will appclr, which canDotbe
rcdistributedin the paracanthal arcaalone.In most cascsthis canlre an-
ticipatedin thc preoperativcconsultationwith thc patient in fio¡t of
thc mirror. Iftoo much sldnredu¡dxncy¿lppears in thc paracarrthrlarcir
lvheu simulatingthc verticll lift, thc pttie¡1twill nced to be colrnselcd
about thc nccessity ofthc tcm¡rorallift.

(lont¡'rindic.rtio¡rs are vcry félv.A ma¡rwith b¡ldnessor ¡ vcry rcccdingtcm-

porirl hirirliuc trrry prescnta chlllcngc fol the phccnrcntof tlre skiu incision.
Horvcvcr',this is thc sanrcfirr rny brorv-lif'ttéchnic¡uc,

OPERATIVE TECHNIQUB

KeyElements
. Horizont¡loricntrtionofthc skinincision
Sutrcutaneous skin underminirg through the MACSlift i¡rcision
Transectionofthe galcato changcfrom a subgalcalto subcuta¡cous
plancrt a lcvcl 2 cm abovcthc c),cbro$,
Urrdcrmirirgofthc tlil ofthe eycbrowin tl'rcsubcutancous levcl
toward thc middle oftlre cyebrow
Suspension ofrhe cranialcdgc ofthe transecrcdgaleato the cranial
galcaat the skin incisio¡rrvith two U-shapcdVicryl 2-0 sutures
Rescction<¡faftw millimctersof skin to m rimizc skin blrlucs
. Suturingwith x running 3-0 nylor suture¡¡¡tcriill
. Suturercmovalwithin ó days
300 CoorbnredAptnches rll S)ncrgisti.l,o.cdur.s

Markings

Filst, tbc mcclill br¡rlcr of thc iucirto bc Lrndctrllincciis tu¡rl<ccl ¡s r curvilin-

c¡r'Iinc (r¿l) rucrli¡l¡nd ¡xrrllcl to thc tcnrporirlctcst,fionr rhc rrriclptr¡rillrrv
linc rrp*irrt1to just lrchinclthc h¡irlinc. Frr¡n hcrc thc 4 t¡r 4.5 cnr horiz(nlt¡l
skin incisionlinc is drawn l¡tcr¡llv in thc h:rirbc¡ri11l¡ sl<in(lulari).I'rrr,rllclt<r
thc skin i¡rcisi(rrir sccondlinc is rlr¡r,n 2 to 3 cnl cilt¡clill,v(ltluc).'l'htsis thc
nrirrkingol thc triursiti()uof thc sLrbgitlcitl to thc sLrbcL¡!¡r'lc()us disscction
pllnc. Irr rnostclscsthis rvill lc¡r,c¡ z()ncof¡t lc¡st 2.5 cnl bcrwcclrthc tail ()f
thc cvcbrow irrrclthc girlcll trirnscction t() ptotcct thc co!¡rsc r¡f thc fio¡t¡l
l¡r¡nch of thc firciirlncrvc, rvhich runs ()n thc undcrslll¡cc of thc fi(]rltirlis
n¡usclc.Thc clisscctionis n()t til(crr nr(nc nlccli;rllvth¡n thc nrirlpLrpill.rlilirrc
ro l)rcscrvcthc supr:rorLrit¡l vesculoncrVous buncllc.
 I f rnirrflr!¡l\i \I i\\'rl frrL r|,Í., .301

l l r c l ¡ t e r ¡ l l r r i t ¡ r l t h c c i i s s e c t i ri ¡sr\rr f . r i g , lc) l ¡ r r r r r ¡ r ' itl l o n r t h c l . l c r ' , rcl n t l r ¡ l

t h c \ l i i n i r r . i s i ( ' r rl .l r c L ¡ r c r l ) ( ) r r l r r ' ( l)llr r J i s s e i t i o ni i i n c , i n t i r r u i rrvr i r h t l r c
s L L h c r t t . r r e oNrlr,s\ ( . Sl i l l t t i s s c c t i o nI l. t l r c b r r ¡ r l i l i i s ¡ r c r i i r r r r r crcr il t l r o L r.tr
, \ 1 . \ ( l Sl i l ¡ . r \ . r r i \ { r 1 . t c (l )l r - ( ¡ . c ( l u f r , i¡nf ¡ o n r h i n ¡ t i o rrrr i t l r. r r rr r ¡ ¡ r c rh l c ¡ l r . r
1 1 ) l ) l ¡ s l \ . l hl cr ¡ r v clri n r i tr ¡ l t l ¡ c t l i s s e c t i oi n s t l ¡ c c r c b r ' , ¡ rx n ( l r ) r ( ) f cl c | l r l ) ( n l,\r
u r r l i ll ) c l ( ¡ \ t\ l r e[ ^ r c s l e | r ' \ ' s l i ¡ r t .
302 Combined Approechcsúd SynergisticProcedu.es

Dissection

In r¡ost casesdre temporalbrow lift by galeapexy is performedin conjunction

with a MACSJift, This makesthe subcutaneous dissectionparticularlyeas¡
becauseit can be continuedthrough the temporelprehairlineincisionmedio"
craniallyunder direct visualizationuntil reachingthe demarcationline to the
subgalealplane.This part of the dissectionis done togetherwith the MACS-
lift flap creationin the beginningofthe surgery.

The ¡estofthe temporalbrow lift is performedimmediatelyafterplacementof

the MACS-lift purse-stlingsuturesand befo¡echeekskinredrapingand resec-
tiou. The brow lift ¡educesthe dog-earformationin the paracanthal and tem-
poral region.This operativesequence is impo¡tant for properskin excess
man-
ascmellt.
 ( . t ) ¡ b r n r r g L h . ¡ l n ( 1 5¡ . f i \ \ I i ( l r( h ( l r n i t , , I L r i 30.3

Frofh bn¡ch of lá.rar rffv.l

t:
I l r c ¡ l i i n i n e i s i o l . p u l r r l l c tl o t l t c l t . t i l s l t . t f i si,s e . l . t i c r lr 1 r l v l tt l t r o L r ! l lrl l l c s l i l t
. r n t lr ¡ . r l c .l r ¡ l r I e r - o t i a J .t ( ) h l t r ( ) tt l l l ) u ! . h l l ) c p c f i o s l c L r r r r ,
304 (l(nnbincd Atti orchcs ¡f d St.cfgisri. l,ro.(htrc\

t'

A subgrrlcrrl tlisscctionis Pcrlinrnc(l bv sPrc¡tlingrviLhlicc lili scissolsro ritc

nrirrliing2 to .3crrrhcl(^vthc sl(inincisit¡n.l hc lrottonrol'Lhcr.lisscction pl:rnc
is pcliostcLrnr in thc rlcrli¡l prrt.rntl tlccp tcnrporirllirsciiiirr thc I.rrclrlprrr.

At the malking, thc tips of rhc f.rcc-liliscissols¡fc o'icntcll uptercl anrl thc
!!¡le¡ is tf¡¡rscctedlgainst cligit.rlp.rlpltionofthc rrondominentfin¡1cr.
 ,, 1 , '..\l\'\J \\' | ,, Ii, .305

\\¡hcn thc sLrbcLrt¡rrcoLrs disscctionis ¡rclti)rnredin c()njLlnction l ith e \lA(lS

lit_t.thc subcut¡ncousplenc th:rt fr:rs¡lrcetli bccn crciltcdis li)unLllcrr c.rsilr.
Whcrr pcliil-mcrl rs irn isohtcd proccrlurc,thc sLlbcLlt¡nc()us.lissccti()11 nlLrsf
bc nr¡r1cfionr this g:rlc:rltrenscctiondo\l\'lr(i, t.ll(in!!crrc 1ttsr.l\'inrhc l)rc
IlrLrsculirrlcvcl until onc rcrchcsthc linritsdcscribcdl)reviouslv.l his irvolr'cs
unrlcrnriningol the eveb¡orv.lhc rlisscctiorr is rrot t¡l<cnnt()fc nlcdiillr'thlrn
thc rrricl¡rupilhlviinc to pr-cscr-rc tfrc supr:rrrfritll rlscukrncrvr>ust¡nnc1lc.
(l¡ur1¡ll¡,,thc subcutrncr>us,:lisscctir¡r ti¡ll¡¡rr.s
thc l¡tcr¡l r¡rbit¡l rinl .ur(lis c¡r-
-lhc
licd oLrtin thc ¡rhnc bctlccn sliin ¡nd thc orbicLrl¡ris ocLlliruusclc. lo\\.cr
crr¡ ()fthc (lissccti()nis ¡hc k¡r.cstctlsc ()l'thc cK^v's l¡cl.

7t

¡t

Herlr()!t¡si\is cnstucrl. lhc bolrlelsofthc tr-rnsectc(1

g¡lcil nccrl thcmostlt
terrti(nr)bcc¡Lrses()nrctimcs:r pulsrtiDgbr'¡Dchof tirc su¡rcr-fici:rltcmpolel
irter\ h¡\ t() Lrec¡LrtcIizcLl.
 r
30ó (.onhi¡.¡ Atti or.hcs,ifd 5\.rfgi{ir lt().(lLLr.\

Lifting

A 2 0 \'icrr'l sLrtLrr-c
or r srnlll, round i r r t i r \ r r r . i l r V n i r ¡ ' 1 , r . . ,i rr r l e . r
ni;rll¡otler ofthc tr'¡nscctcdqllc¡ itsii II , ,r'i . , ,Irr.rI I ' . l . . r , l . r r r r r ' , , l . r c r i r r
tcrring rhroueh thc gitlcirlbolrlcr).
 -

(i,nrbnri.g
rh.I1ACSLitilviü rhel.r.por¡tLih 302

l3t ¡rrrllirrgon tl)is sufLtrcthc cthcic¡q,ol.thc cyebrou,lifi clrr bc rlctcr-minctl

308 (bDbnicd Aflr(¡drcs.,nd Sy¡cfgisri. l,ro.cdu.cs
I

t'

'lhc
st¡turcis ¡tt¡chcd pr()xiDrlllvto fltc liillc¡ ¡¡ thc skin incisir¡r.¡lso in rr LJ
sh.r1>ct1
tirshion.Il thc dccp tc tporrl fiisciiris sccn,thc sutUrcc¡lt ills()bc ¡ t -
firchc(lhcrc. ltro or thrcc 2 0 Vicn'l sutLrrcs ¡rc pl¡cc(l bcfi)rctvinl¡

Tlle tr,ing iq clonc ". thc irssistirntpnshestltc tcmporil sl(in up\\,¡rcl f-orr¡exint.rl
colrcction. A nterkcdriclgel¡ccontcsvisit¡lc.This ridge will rclndin fLr :Ibolrt
ó \'cclG Lrntilthc Vicr\'l sUtLrrcIosesits brcaliingstfcDlrth.In tlte Dc¿ntin,c,
thc sLlbcLrrrrrcous scilrringlill hlvc fircc1thc ct'ebrorvin its nct position.
 ( r { ) n , L r i n irdh{c I l . \ ( 1 5 L i f i r V i r r r l r eT c ¡ i r ¡ r l L i i i 309

UsLrrllr', ii l.:u'r¡illinrcrcrsof skin c\ccrs nccd t{) L)cIcscctc(i,n()t li¡.¡hc striril

i t i ' o f t h c r c s L r l lr¡,u r t o t l i n r i n i s thc
l r hciglrt of tirc skirrrirlgc.

'l
hc sliin is closcrl u itlt i1funnir!¡: 0 l¡,lon suturc. l lt ch is rcrrrrn.cdon
¡ost
()l)ef¡tilc d¡v 6 t()gcthcl \\'ill1 thc licc ljfi suturcs. As rhc sl(ilt cdllcs
¡fc
ptrshctl togethcr br thc !¡,¡lc¡l¡crr.slllLrrcs,thcrc is ¡bsolurclv no tcnsir¡r on
thc skin cLlscs,¡lld thc sc.lf quxlity is itl\\'il\rse\ccllcltt.
3r0 Cor¡biDed App.oaches aDd Svne.gisticPro.edures

EXPERIENCE WITH TIIE MODIFIED TEMPORAI

LIFT BY GALEA?EXY
We have been using ttis simple and effective technique for 3 yearswith grow-
ing enthusiasmin ll8 patients.The majority (96) of procedureswere per-
formed in conjunctionwith a MACSlift, and the remaining22 asan isolated
procedure.Initiall¡ we appüedAlain Fogli's techniqueunchanged,but asex-
perietcc grew we eliminatedthe subperiosteal dissection,becausethis made
tie operationmore tediousand lesswell-tole¡atedunde¡ local anesthesia in
our hands(seeChapter8). In accordance with ou¡ convictionthat a facial¡e
juvenationshould be asantigravitational aspossible,the directionof the inci-
sionwaschangedfrom perpendicularto the temporalcrestto strictlyhodzon-
tal. This allowsa purelyverticalelevationofthe eyebrowand paracanthal skin.

Basicall¡this tcchniqueis equivalentto a subcutaneous foreheadlift without a

skin cxcision,and linited to the lateralpart ofthe foreheadwheremost ofthe
correctionis needed.As a consequence, the hairlincdoesnot ¡¡ove and the ür-
cisiondoesnot showasit liesbehindthe hairline.

Thc wholc proceduretakes10 minutesmore time per side.It is simple,efli:c-

tivc, and saic with regardto vascularityand the frontal brancl'tof the fhcial
ncrve.

Thc¡e is a short learningcurve fbr thc surgeonand few problemsto be cx-

pected, even with limited experience,We had two unde¡correctionsin our
earlyseries,probablycausedby ar insufficientunderminingof the eyebrow.
Limited sensorychangescanbc expcctedir somccascs,becausethe horizon'
tal incisioncrossessomesensorybranchesofthe supraorbitalncrve,
 Conbi¡ing tbe MACS Lift With th€ Tcmporal Lift 3rl

Anothcr disadvantageis bulging of the skin in the ftontotemporal a¡ea for

ó weekspostoperatively,which can easilybe maskedby combing the hair over
the forehead.Only in patientswith a very short haircut and in men with
a recedinghairline does the placementof the incision require a little more
creativiw.

Furthermore,thus far the(c havebcen no hematomasrequiringsurgicalrevi-

sion and no ftontal branchproblems.

The technique hasmany more advantagesthan disadvantages.In conjunction

with drc MACS-lift, it reducesthe bulging of paracanthalskin. As a conse-
quencc,it reduccsthe length ofthc lowcr pi[ch blepharoplasty incision,espe-
ciallythe paracanthalextcnsion,by takingoverpart ofthe verticalskin redrap-
ing. Thcrefore this temporal lift is currently addedto a MACS-üft in more
than two rhirdsofcases.

Many of our patientsare resistantto brow lifting for fcar of ovcrcorrcction,

Nevertheless, the mechanismand thc advantages oflifting only the tail ofthe
eyebrowand thc effect in thc temporal and-paracanthal¡egion are easyto
demonstratcto the páticnt in front of thc mirror. Isolatedor with a MACS-
lift, it producesa very naturalrcjuvcnationof the cyebrow-paracanthal region,
without any risk of overcorrection.This standsin contrastto some subperi-
ostcaltcchniquesthat ca¡ movetissltcsout oftheir anatomiclocatiol,

To concludc,this adjunctivetechniqucñts perfectlywith our philosophyofef-

fectivebut simpleintervertions crcatilg naturallongJastingresults.It hasa
very comfortablcposition on the risk-bcnefitbalancccomparedwith many
other tcchniqucs.In the spectrumrangingfrom aggressive subperiostcalbi.
coronal brow lifts to the suspensiontechniqueswithout undermining,the
temporallift by galcapexyhasbccomeour plimary choicefor the cor¡cctionof
the upperone third ofthe face.In combinationwith the MACSJift, it wasthc
"missinglink" toward harmoniousfacialrcjuvenation.
Conbined Approaches
and S)'ne¡gistic
P.ocedu.es

CASE BXAM"LES
Ae*betic Analtsis
This S3-year-oldwoman presentedfor facialrejuvenation.Shewas especially
concernedabout her neck and eyebrows.Shehad submentallaxity with two
hear1,platysmalbands,somejowling, and markednasolabialfolds.The eyelid-
cheekjunction wasstartingto develop.The uppereyelidswerehollow and the
eyebrowslow, producinga hooding in the lateralpart ofthe eyebrow.

This procedurewas done ulrder local anesthesiawith int¡amuscularmidazo

lam relaxation(3 mg) and took 2 hours and 30 mi[utes. The patientwasdis-
charged2 hoursaftersurgery.

Surgical Plnn
The ueatmentconsistedof:
. Submentalliposuctionand suctionofthe jowls
¡ An extended MACSJift
. A lower pinch blepharoplasty
. A short-scartemporallift by galcapexl
CrlnL)ni.g ¡be ñlA(lS l,itiWi¡h thc lt¡rNnl Lili 3t3
3l -{ ( ,, r r r(J \¡fr1,.,.,r. r rl \\ r, rf.tr. l'!).!,lL,..

I'ostoptratirc lltsrr lts

l h c p o s ¡ q r | ¡ ¡ . 1 ¡ j ir.( \ u l 1 \ ¡ r c \ l r ( \ \ r ( ¡ . r r 1 1l l r r r o r r t h s . r l i cslL L r g c r (r ) ¡ l l o n t . r l
r i c r r . t h c g c r r c r ' . \rllr ¡ f c ( ) l l h c i i . r i \ . h . r n g t r l f l r ¡ r r . . r . r l q L r l . r ¡ t ¡ n r o r e o r . r l
l r r ' c ¡ u s co 1 t l r e l i g h l c r n c . l i . \ ¡ ( l . , ) r r r . 1 i ( ) r ro f j o l l i n g . I l r c n r o ¡ l . r t r r n . r L
h . r r J s l ¡ . r r cL l i s . r l ' ¡ r e , r r (c),nl t h c o b l i r ¡ L r \ci ( \ ' . i n r p r ( ) \ c n r ( r )irs s c c n i n t h c l ¡ c t
t c l L l c f i n i t i o ror l t l r c n r , r n r l i t ¡ u l .Lr ¡r r ) r 1 l cl fh. c s o l l c f r r , r s r ) l . r b1i ,or l i l .¡ n r l r l r c L ¡ c r
t ( f \ ( , l u n r ci n t l r e ¡ r i J l . r e cr i t h . ( ) f f r . l i o r r ( ) l l h r : i n l l . r , ¡ l r l t , rl lr ¡ r l L o r iI.l r . l . r t i ,
. r l ¡ l . r f r ( ) lt l r c r \ r l , f ( , \ i s i n ¡ I r j g i r e fl ) , ' \ l j r ¡ n e i e n . r l i i r l l ¡ r , r ¡ t l r s . I l r e s l r , ' r t
\ r . r f r ( r l f ( ) r . r l l r l l l r , r sr i ¡ c l r r c j r r i e r r , r r et.hl t t i r e , l l ¡ ¡ r l i \ \ r r h , ) u r r ( ) L r ! l t r r rrql r (
u l ] ] ) e f c \ c l i ( l s l i r f l \ ' r ' l o I r r i n , r . r r rL r l ¡ l ) r rl ) l c l ) h . r ( ¡ ] r l . r s$l r, r u l . i h . r r c I ' i c n . r
t r r o n q L i c e i s r r ¡h . r , r r s r ( ) l t h ( | n r ¡ r r x i t i o n( ) t t h c c \ ! l ) f ( ^ \ \ . \ l s o i n t h c | r ' o
j i l e r r t r r . t h c a l r . r r r q cr r a u r \ . r t u l c o l t h c c n t r c c r e l ¡ r ' r ¡ r r c s r l t i n q l i ¡ r r r l l r e
t e r f l . o r . r l i l i ( . ü r . l ( , l r ' l vh c s c c n . \ l l e r ' l l n r o n t h s .t l r c l , o s i t i o r o r i Ilrccrcl'r',¡
L \ r , l . h . l | j q ( ( l l l r r ' . l r , r n q ci r e Ü r i ¡ , , n r c | l t . r.lr r s l r r ' . r n , l l \ (l)) l J\ c e i r l r ( l ) r ' , )
l i l . \ i ( \ . \ ( , 1 ( r l r , r rr h ( f e i \ ¡ n r | l i f l . l l f ( l . r \ . l l i o n¡ r l t l r c s f l r ¡ l r e r r t . sr lI ] | ¡ . r l i
I t c . r r ' . I h c ( l r r . l l r l \( ) l 1 h c s . . r f i r r t l r r l ) f r . r r f i . L r l . r. r r , 1 t t r r l r r . r l l r . r i r l i r r cr '
! . , ¡ ¡ i , l ¡ t ' f n r i l l i ¡ " t l r c l ¡ . r i rt ¡ r 1 ¡ cr ¡ ' r ' n l ¡ h r r L l t h c c . r ' .

ri m.nr¡. rri'4rr ¿v.r l f n r o ¡ 1 ¡ sp . s t 0 t i . , ¡ r L , r y

 ( ( D , h , ¡ i . s r h r i \ ¡ A ( t Sr j r i \ \ ' i ¡ hL h r l ¡ j r ¡ ! . ¡ L
LÍi 3Is

6 monihsDósloper¡l
verv r 2 r x r r i r s n r . r on y ¡ i ! . y

12 nrofllrs posroperátive
y
3ló Combired Approaches¡nd Sj,nerg¡ti. l.o.edur€r

Aestbetic Analysis
This49 ycarold mancomultedfo¡ facialrejuvenation.
He lookedolderthan
hc felt andwantcdmatimalimprovement. He hadundergone anupperbleph-
aroplasty 5 yearsbefore.He prcsel1ted
elsewhcrc with healy,thick skin and
generalsaggingofthe face.He had somefatty i¡ñltratiotr ofthe submental¡e
gion and ptotic jowls, deep nasolabialgrooves,and a heary fold on top of
them. His midfacewasdescended with a distinctc¡easebeÍveenthe cheekand
thc lowcr cyclid, lvhich wasbulging fiom the lower cilia toward the infraor-
bital crease.The upper eyelidswerehollow and the eyebrowwashea\ryand rn
a lorv position.The tail ofthe eycbrowwasdrooping, causinga lateralhood-
ing deformity with two or three deep horizontal crcascsitr the paracanthal
area.He showeddeephorizontalrvrinldesin the frontal area.

This p¡ocedurewasdonc under local anesthesia with intramuscularmidazo-

lam relaxation(4.5 mg) and took 2 hours and 40 mirutes. The patient was
dischargcd2 hoursaftcr surgcry.

Surgicnl Plnn
The treatmentconsistedof:
. Submentalliposuction
. AI extendedMACSlift
. A lower pinch blepharoplasty with transconjunctival
resectionof
fat f¡om the three compartments
. A short-scartemporallift by galeapexy
Co¡rbnlng thc MACS Lifi With rheTeDrporalLift
3r8 (.¡h,f&l Atti,¡.1,.\ ¡ri¡ Sui.,gi{i. 1,,,).(1L,,ti

PottopcrotireResubs
I hc p¡ticnt is sholn I \\cclis.rril c) m()nths ¡ficf sLtfl-tcrv. Hc sh{)\s .rr .l(le
(lu¡tc c()rrcction ()11hc ccrricorrc t¡l .r¡slc. I Lrct¡clrlclinili(nt ()l lhc Ir. l(litr
ul¡r'Lro|rlcN l ith c()rrccri()o nf thc jo\ls, rDrl I susPcnsion ol thc sub|l.1|l(litr
L r l i l f! l h n L l b v l h c . r , r r r ¡ l s u s p c n s i o uo f t h c ¡ r l l i s n t . r . l l ¡ c ¡ r . t s o l ¡ b l ¡sl l r x ¡ c
litlcd .¡¡Ll tllc nri(llicc sh(¡\'s.l n¡1r1r.11 fcl)lcrrjshrrcnt. rith rlntost contplc.-
cr'.rtlic¡¡ionol thc cr clirl chccl jLrrrctiorr. l hc nr¡l¡l r¡¡luntc is in .t ltigltcr ¡osr
rion. civine ¡ \'()Lrlhlillnr¡l¡r ¡usrrrcrrrrrti()ncffc(t thiLt crn L)cslL)c.lpIrcci.lfc(l
( ) n f h e ( ) L ) l i q L r\ icc \ . 1 h c c J l c . l o f ¡ l ¡ c t c ¡ r p o r ' ¡ l l i f i c ¡ n ¡ l s o L r cs c c l ¡o l r r l ¡ r s
r i ¡ . r r . I h c n r c t l i ¡ l p . r f 1{ ) l l l r c c l c L ) r ( ) \ \ ' i isn t h c s ¡ n t c l ¡ ( ) s i t i ( )¡ns l ) f c ( ) l ) r r . r r i \ c , \ .
\ h c r c . r sl l r c t ¡ i l o l r l r c c r c L r l r ¡ ri s l ¡ i s c d ¡ b o u t I c n t . l l r i s r j i r c r . r n . r ¡ u l ¡ lt i c s h
c r l rr o l i r r i t h o L r t¡ n " ¡ s t o n i s h c t l "c l l i c t . r r l ¡ i e l rc , r r rl ¡ c c ¡ L r s c tLl r vt h c p o s i ti o l r o l
t h c r 1 1 c ( l i c¡ l c l ) ¡ ^ \ ' L ) c i n s t ( x ) l ¡ i q l ¡ . l l ¡ c c k r s eL r pv i c l o l t h c s c r r r s l t o t s t l t c r r
q r x x l q r r ¡ l i t r . l h c l c i ¡ r ¡ l ¡ v i o L rhs. r i r r c q r o \ \t h t h r o L r g l tt h c l c n r l ) ( ) f . rsl . . r f l ) c
c . t u s co f ¡ h e t ¡ n s c n t i . r ld i f c c l i ( ) r ro l ¡ l r c i r r e i s i o ri n t l t ¡ t ¡ l c ¡ . L i s i n g t l t i s r c c l r
r r i q u c . h i L i ri i ¡ l l i c l c s . r ' cs . r r c t lr n t l c r ' t h e i l t c i s i ¡ l tp l . t l c . r n d l c g r o t r t l r s r . r r ' l ls
l . : r r rrr r ¡rr I ir s . rJI c r s u r ' q c l t .s ( ) t n c t i n t c cs ¡ L l s i l r qe t s t s t ( ) . r l ) l ) e ¡ f¡ s s o n t c l t ¡ i l s
q | o \ \ i r r . I I i r l ¡ c . U r rl n r l s i r l c h U l n s . r f cs l i l l i n . t . r n i r t o r l l i cp o s i t i r r ni r r l f ( ) r ( ) J
t l r c r . r f r r r ( l r ( ) l ( ) L r l( ) l t h c 1 f . r g , l s . . li\\ o l i c r ¡ r c c n ¡ l i c l l ¡ t c ¡ - l lt r l c t i r ¡ n r ¡ n t l . -
e l r c c l (l l r r l ) .l h c r l L r . r l i n( ) l t l r c : 1 l r r h o r i z o n t . r ls c l l l i o n r t l r c t c n r p o r ' . rl li l i L '
l ) c f 1 ¡ c t .l h i s s ( . r f h i r s n c r c r ' P o s c r. ir r r !l ] 1 1 ) b l r r )br ,c e . r L t sscl i i n i s c l ¡ r s c Lt ir t t l t r ¡ L r t
.rr\ lr.r(li()n.

'\#'

2 vrcekspostoperatve y I morths F.stop.ral ve y

 (.,!¡hif )g rt \i^( S L i \\'jrh nr. l.fr¡r.rt Ijt¡ 3t9

2 w{¡ks postr)p.ralve y qr¡.hsl

llt I

I monthsp.sroperar
vc y
32O CombinedApprolchesand Synerg¡ticProcedures

Aeaheti,c Analysis
This S4-year-oldwoman consultedfor facialrejuvcnation.Shewas especially
focusedon her neckand her "look," which deterioratedsignificantlyin recent
years.Shepresentedwith a lax, fatty-infrltratedanteriorneck,with two hea\'y
platysmalbands.The jawline was interrupted by a heary jowl from which a
marked ma¡ionettegroove ascendedtowa¡d the co¡ner of the moudr. She
showeda mode¡atenasolabialfold and a descendedmidface,with a clearde
marcatio¡betweenthe cyelidskinand the cheekskin.Her uppereyelidregiot'r
washollow widr a low positionofthe whole eyebrou At the lateralpart ofthe
eyebrow,the tail wasptotic and producedtwo or thrcc decp folds known as
lateral hooding.

This procedurewas done under local anesthesiawith intramusculatmidazo-

lam relaxation(3.5 mg) and took 2 hours and 50 minutes.The patient was
discharged2 hoursaftcr surgery.

Surgiaal Plan
The t¡eatment consistedof:
. Submentalliposuctionand liposuctionofthe jowls
¡ A¡ extendedMACSlift
. A lowe¡ pinch blepharoplasty
. A short-sca(temporallift by galeaperl
Combi¡iDgthe MACS Lift Wirh the TcmporilLifr
CombincdApproaches
a¡d Syncrgific Prccedures

PostoperatiyeResalts
Postoperativercsults are shown 8 months after surgcr¡ In the neck the ccrvico-
mentd anglc is markedly improved, with adequatc correctioo ofthc platysmal
bands, and better definition ofthe jawline, wirh correction of thc jowl irnd
marionctte-groove deformiry In the midñce, a nice effcct on the nasolabial
fbld is seen,as wcll as a distinct lift ofthe malar volumc (which is best apprco-
ateclin thc oblique view) and a reduction in thc vcrrical height of thc lorver
eyelid with tightening ofthe lowcr eyelid skin. Thc lateral part ofthc cycbrow
is in a highcr position,corcctilg the lateralhooding. The "looh,,has l¡een
opencd (close-u¡rview), and the patient has a yourtger appearancc.If a tempo-
ral lift had not becn added to an cxtcnded MACS-lift proccdure, the tcnporal
hooding would not have been corrected or may havc even been aggravatcdby
thc bulging ofskin in the paracanthalregion rcsulting fiont thc vcnic¿tllifi on
the dccp subcutaneoustissucsil¡d the ski¡. Thcrc was no retroauriculirr dis-
section, so there is no rctroauricular scar.
 323

t'

t
h
,,.
,'f
G,

1
{

1
.ít* -':.'t\ '
\i
iJf f;
i
-1¡*
t
324 combinedApproaches
and Sy¡ersúticI'rocedures

Aeobetic Analysis
This 47-year-oldwomanpresentedfor facialrejuvenationsurgery.Shesmoked
halfa packofcigarettesa da¡ This patientshowedsomefatty infilt¡ationin the
neck,rnoderatejowling, ald marionettegrooves.The midfacewasbeginning
to descendand had mode¡ate nasolabialfolds. some infraorbital hollow. and a
downwardcurvatu¡eofthe lateralaspectofthe eyebrow.The medialpart of
the eyebrowwasin a high position.Shehad hollow upper eyelidswith no skin
redundancy.

This procedurewas done unde¡ local anesthesiawith inuamuscularmidazo-

lam relaration(3 mg) and took 2 hoursand 45 minutes.The patientwasdis-
charged2 hoursafter surgery.

Sargiaal Plon
The t¡eatmentconsistedofi
. Submentalliposuctionalld suctionof the jowls
. An extendedMACS-lift
. A lov/cr pinch blepharoplasty
. A short-scartemporal lift by galeapexy

Postolara,tiy e Re salts
The postoperativeresultsarc shown 1% yearsafter surgery.On the frontal
vieq a more youthful oval shapeofher faceand a higherpositionofthe later-
al part of the eyebrowarc seen.Thesea¡e better seenin the oblique and the
lateralviews.Note alsothe reducedjowling and marionettegroovesand the
fadednasolabialfold. The tratrsitionofeyelid skininto cheekskin is s¡¡oother
On the lateralview, the cc¡vicomentalangleis better but not perfect.A low
digastricbelly is probably showing through the skin. Although shc had no
temporal hooding, a temporal lift was suggestedbecauseof the thick skin
bulging in dre paracanthalregion after a vertic¡l face-liftmar¡euverwas per,
fo¡med in front ofthe mir¡or
( r ¡ r 5 l i r ¡ r rg i r \ l \ ( \ l , r l\ \ r r r r l r . l t ¡ f r ! r l l . i : 1 .325

}
Combinrd A||ro¡chcsrnd S]n.rgisriclrocedurcs

AestheticAnnlysis
This 50 year-oldwoman prcscntedfcr facialrcjuvenation.She had a short
haircut and was not willing to change this habit. She only wanted to have
surgeryifeverything could be done under localanesthesia. Sheshowedmod-
crate neck laxity with some fatty infiltration, moderatejowling, and mari-
onette glooves.The co¡nersof her mouth slanteddownwa¡d.Thc midfbce
wasbeginningto descendwiti moderatenasolabialfoldsand a distincteyelid-
cheekjunction. Her eyebrowwas ptotic in the lateralpart and some l¡teral
hooding wasvisiblein rhc paracanthal region.

This procedurcwas done under local anesthesia with intramuscula¡midazo-

lam relaxatiori(3 mg) and took 2 hoursand 30 minutes.The patientwrs dis-
chargcd2 hoursaftersurgery.

The patienthad undergonean uppcr blepharoplastywith skin/musclercmoval

and cmptying ofthe two fat compartmcnts5 years carlicr at our faciliry She
alsohad a lowcr transconjunctival
fat lcmovalofthc threecompartmcnts.

S*rgioal Plan
The t¡catmcntconsistcdof:
o Submentalliposuctionandliposuctionof the jowls
. An cxtendcdMACS-lift
. A lowerpinchblcpharoplasty
. A short.scar
tcmporallift by galcapcry
r o . ' l . r i . ' g h c I { , A r< I l \ \ ' i r \ , \ ' T ( , ' t r ' l l l
32ll ( ¡ , , , t ) i n . d . \ t t n ) . \ h c \ . , , i J\ \ r r i g i r i . r , ¡ { . ¡ f r \

Potto p ct'ttt i ve Rc t t I It s
'I
hc rcsults.rrcsh¡rrrnl2 months post<4rc.illi\clr.l lrcrc ¡pl)c¡rsto lrc ¡ st¡lr]c
c(nrcctiolr r¡l tlrc ecrric.rll¡rit! rrith sh.rrpcniDq ofthc ccrr ico lerrt.ll.rrclc.
I'oh.rl¡sr tlig¡stricr¡uscleis risitrlcirr thc PostopcrirtircrcsLrlts, srill oblitcr'.rt
i n u ¡ h c c c r r i c o ¡ l c n t i ¡¡lr r q l c .( l ( r ' f c ( l i ( ) ¡o f t h i s l t ¡ L r l t l l c q L t i r eo p c n i n gt l r c
r r l t o l c l c c k ¡ n d l c n r ( ) \ i u r r r r l c i r s l x l ) l f t ( ) f t h c m u s c l cl h. i s \ \ ' . r n s rf rliseussctl
\\ rfh thc piLlicrrl,bcc.rusc il \<rLrlritorn thc surqer! ilrt().r In.rj{'r .3l() + lr()Lirrl
tcr\cntion lirr-rvlrithrtcncrrrl¡ncsrhcsir\\()tlld bc ncccss.r'r. Shc slrorrs.1|r¡tl
c(lurtc irnd st.rlrlce¡¡rcctir¡r rf thc jor!ling ¡rrcl rir¡rrrlrr¡rcl sl.rntirrqol llrc
r r r ¡ ) l r t hT.h c c l l ¡ c l r ¡ l ¡ h c t l l i r r lp r ¡ r s c\ l r i n g s u t l ¡ r !r ) n l h c n r i d l ¡ c ei s l ¡ c r t r c c
o n t h c o l r l i q u c r i c r r .l h i s c f f l c rc a n . r l s o L r c . r p p r - c c i . r )t rcrltllr c t i ( ) n r . L. rl n ( ll ) f ¡ )
l i l c r i c w s .H c r n r i t l J i r (sch ( ¡ \ ' si r ! i c r ) c r xl lc p l c n i s h n r c n\ \ti l h ¡ r c ( l L r . l i { )(r)rl l l r c
\cfficltl hci!tht r¡l thc Lxvcr cvclicl.rnil .r l.rilirq ofth( ctclicl chccli jLrrction.
'I
h c s cr c s u l t se, ¡ r ¡ [ r i n c dr r i t h r h c a ( ) r r c c r i ( )orf]c h c t c r r r p o r .lrrlo o t l i n gb.r l i l i
i r r go f t h c l . r t c r . lr)l ¡ r ' t( ) l t l l c c v c l ) r ( ) \ r\ .c h i c \ cr r ) . r n r r , r lrl'rc l i c s l r cidl r L . ' l l r c
c l L r . r l ionl t h c l l n ¡ l s c . r r r . r sq r x x l . ¡ r ¡ (tll l c p J t i c n lc ( ) n l i l u c ( ¡l r r r c ¡ r h c ¡ l l . r i ¡
\h{) .

Bcforeb epharoplasly 2. mo¡1hsaller lrleplraropasly

(s ycars beloré I¡ACS ltl) 1 sy e ¡ r s b e r o r eM A C Sl r l )

It isintclcsrinL q oe o r r r p r f tch c l ) r c { ) p c f . t t i i c . r p¡ cols t t l r c l ¡ t i l cl ) l t ( ) t ( ) g r i r p(h) ls'

llrc clclid slrr::err()l-5r'c.rrs¡qo l i¡h thc ¡rcr4rcr'.rtirc.rntl l)()\r(tllcfirtivc vicN\
¡ l i c l t h c . r r [ 1 i r i r ¡ nn¡ rl i i l t i c cn d t c r r P o r ' .lri lt i 5 r ' c ¡ r -ls. r t c r .
(.on,binrrg
r b r ñ l ¡ \ ( l St _ j j i \ l ' i ¡ hL h r ' t c r \ ¡ , r t.jii 329
330 Coñbinc¡l Appro¡chesand Syn€rgistic
Pfoccdurcs

Sargical Pearls
. An upper blcphaloplasty does not solve the problem of a ptotic cye-
Drow.
. Vertical lifting techniques such as the MACS-lift often generate a skin
gatheling in the paracanthalregion that nceds to bc addressed.
. Needle surgery (botulinum toxiD) has replacedknife surgery in the mid-
dle third ofthe forehead.
. The short-scar temporal lift by galeapexyis esscntiallya subcutancous
brow lift limited to the lateral third ofthe forehcad.
r Ovcrcorrcction is virtually impossiblc,in contrast to subperiosteallifting
techniques.

BIBLIOGMPHY
FogliA. Temporallift by galeapcxy, A revicwof270 cases. Aestheticllast Surg27:159,
2003.
IsscNG. Endoscopic forchcadlift: Evolutionandupdarc.Clin PlastSur' 22t66l, 1995.
K¡rizcl)M. Limitcdincisionforchcadlift for cycbrowc¡cvationto cnhanccuppcrblcph-
aroplasty.I'lestRcconstrSurg108:5ó4,200I.
M¡iarassoA, HutchinsonO. Evaluating rcjuvenation ofthc forchcadand brow:Arralgo-
rithm for sclectingthc appropriatctechnique.PlastReconstr Surgll2:1467,2003.
MossCJ,MendclsonBC, Trylor GI. Surgicalan¡tomyofthe l¡gamentous attaclrmcntsin
thc tcmpleand pcr¡orbitalrcgions,PlastReconstrSurB105:1475,2000.
PaulMD. The evolutionofthc b¡ow lift in aesther¡c plesticsurgcry,PlastRcconstrSurg
108:1409,2001.
RanrirczOM. Thc ¡nchorsubperiosteal foreheadlift: Frornopcnro cndoscopic. Pl¡stllc-
constrSurgI07:8ó8,2001.
ScckclBR FacialDangcrZoncsiAvo¡dingNcrvcInjury in F¡cialPl¡sticSurgery. Sr l¡uts:
QualityMcdicalPublishing,1994,
 The Synergyof
MultimodalFacial
TI
Iteluvenauon
Patting It All Together
ThomasL. RobertsIII o TerrenceW Bruner
ThomasL. RobertsfV
(in¡biD.d Appn)¡(hcs
andSrn.rgirit Prcüdur.s

\
t ).lrrr'rry suggesrs thrr the \\ holc crrn bc grcitcr thin thc sum of its parts. As
sLrrgcons, wc see a pxtient recluesting i fircc lifi, thcl \\,c pcrfb¡m ¡ facc lifi us-
ing our bcst skills and tecl'rniqueucl (hopcfirll,v) gct ür acsthcticallyplcxsin!!
fircc-lif-tlcsult. But clid lve obtain fbr oLrrplrticut thc r¡ost natural, harnorior.rs
¡ppciuirucc possiblc n'ith a gcluincly younger lookl Althouglr e goocl short-
sclr tircc-liti technique is thc ¡ppropriirtc Norkhorsc and anchor of nran-vflciirl
lcjuvcrutions,it is possitrlethlt othcr, snrillcrsiñultancousproccdurcs,whcn
s cll-thought out and inrplenrentcd<>¡rtirnx¡ly, cÍrnin somc cascsh¡r'c ¡s nltrclr
or rrrorc cf-fc( on ¡he final resulr rh¡n rhc ficc lifi. This conccpt is dcmon'
strirtcd by thc pxtient pictured bclo$.

()btii¡ing this clurlin ofrcsult rvith rcirs<¡nirblc consistcncvrequircs(l ) clrc

f¡l plticnt sclcction, (2) irn undcrstirnciingof thc p:lticnt's goirls anci spccilic
rcqLrcsts, (3) krrorvleclge of iclc¡l flci¡l proportions (fbr thc paticlt's s¡'rccific
cthDic group), (4) the lbility to ¡n¡lvzc thc pirticut'slcssthan-iclcalpropor-
tions irnd spccificchangcsthat colnc with thc dging proccss,(5) fiurilirrlity
rvith thc diflircnt nrod¡litics¡vrilll¡lc to lcconr¡rlishficial rccontonringlncl
¡clcircss tlrc chlngcs of fircill .rging,((r) insight ¡s to \\'hich moclaliticsto usc
firl c¡clr p¡ticnt ¡ncl to rvh¡t cxtcnt to dcvclopthc sulgicalplan, (7) thc srrrgi
cal judgnrcnt,cxpcricncc,¡¡rclskill ¡rcccss¡r'r,kr inr¡rlclncntthc ¡rl;rn,antl (ti)
thc dcsilc ¡rtl .rbilin'(alcl stlfl) to nurturc irntl su1'r¡rrtcach¡rlticnt thr<xrgh
thc \'¡girics ()frlrc hcalingproccss.

FtG, l0-l

Aqe60 (posroperálive)
 Lhr syf.,sv oi Ilultnn(¡t.n F¡.irl ILjL¡cnrLi(m l\,úrg I' ,\ll li)gfthcl

UNDERSTANDING THE PATIBNT'S

REQUESTS AND GOALS
Thc piltierrt'sspccilicrctlucsts.urcl qcner¡l qoils ilrc l(cl to obt.rininerhc high
cs¡ l)crcent¡qeof-p¡ticrltslho ¡r'c s¡tisficcl(oL cren cro-crnclvplc.rsetl)rrith
-lo
tllcir sr¡rqcrf. undcrsturl Nh¡l thc ilcsthcticflci.rl surgcrv prticnt rc.rlh
l lnts rcrlrrir-cs Ixrking bcr,onclhis ol her sPecilicreqltcsts.S()nrcPirtientslcl]
us c\ilcrlr Nhi.h procc(iltlc()f l)r()ccdlrrcs lhe\'\\'.¡r]t(s()r¡rcti¡rcs
in c\cfr.¡ciilt
ing rlct:ril).Horvcver.nr<;stpirlicntskno\\'\\'h¡¡ lhe\'(iislikc ¡Lror¡ttheil lir,.,
h¡r'c sor¡rciclc¡s.rboLrtwh¡t nccclst() l)c dorrc,lrut scckour irdricc(nr (hc L)est
s()loti()nt() fit thcir ¡tccclsar1(ifirl¿nccs. llcfirrc rliscrrssirtg
spccifi¡:pr()ccdr¡rcs,
rrc nccd to l¡¡ldcrst¡¡rci thc l)rticnt's cxprcssctltlcsircsud uns¡rokcnor sulr
c(nrstioLrs llo.rls.l)rticrrtssccliingficiirl .rcstlrctic sLrlgclvgcrlcf¡llr fill int{) li\ c
grou¡rs,cic¡rcnrlinq t)n (llcir q()¡ls(il fininci.¡lc()trstr¡it1tsrr'crcelinri¡t.rtctl):
l l)lticnts \\'h()¡rc s()nrc\'hit tirrricllcgirrclingch.rngcs:rrrclnriglrt s:rt,."1
vaitt ln luh liltt u\stll,.irn n littlt lt¡s ¡ittd; n littlt ntrtt¡r'r u'ouldbt
,ic¿." An\, chdrrgcin thcsc l)¡ticnts r¡Lrstbc conscrr:rrivc:rntl¡rlhcrc
rigitlh to rhc linritsrlrc p.rticnt¡rl.rccs. A sn)¡ll!.lfi.rti()1,cycn il it \'{)old
l{x)l([)cttcf,n)ill ci¡lrsc¡rr iclcrrtitycrisisirnd i vcrl urll]ilppl l)ilticnt.
2. l)¡ticrr¡s \\11() "D'rr7rf¡0 lollt tL. [tttt pori[tlt-liltt I did ¡'ltt¡¡ I ¡'ls
1t0t!it!lü'."lftrc nrrrt'lrc¡ cl¡ssfcuni{)nc{)¡ring lrp ()r lhc \\'c(l(ling()f il
child (n's()r c ()thcrc\trfrr¡l I]r()ti|irti(nr.Ir is crtrei¡lfi)f thc sr¡fgc()nt()
h¡tl out il thc¡c ¡r-c¡nl such dc¡rllincsto cnsurclhirt therc is cnou¡r,h
tiurc !iu rcc()\crvlionr sLrrgcly,ils wcll ¡s li()nr ¡rossiLrlc eoru¡rlicltirrrrs.
'li)
rrrissthcsctlc¡clli¡csrrill lrring tlrc P¡tic¡t c\trc¡rc tiustrirti(nril¡rl
cnl l)illl rlssntcDt.
3. l)irticnts\'lr) "n'tr¡ttto luoltbttttt tl.¡ttt¡I ¿t'tr lootrt¡l."Tl¡is qr()Llpirrclrr(lrs:
. lh(Jsc\\,ho h¡r'c sr¡¡c lirci.rlclis¡rr'<4rortion (fit cr.rnrPIc,Lrigrrosc,
sc¡k chin, fl¡t chcck boncs.o¡ rhin li¡s)or sinr¡rh.r pl.rinor-honrclr'
irl)l)cxrir|tcc.
. 'l lÍ)sc who h¡rc gr¡re th¡r)rrqh(or irrc itlrtut to Lr¡(lcrgo)s(nncnt.,
jor Iifi tr.rnsitionirnclrlirnl ¡ ficslt st¡rt (lir e\il¡trplc,rlirrrlcc,clc.rrh
()l r sp()!sc,.l nr¡¡¡ ciuccr chi gc, ne\1r ¡cqüirerl rcs()úfccs¡ll.¡t
pcrnrit ()nc to c<¡lsi¡.lc¡ ilcstheticsurgcr\',(x cvcn rctitc¡rcnt, \\ hicll
nrry ott¡r thc tirst op¡rortunin t() tirkc cnouqh tinrc ()fll() rcc()\'cr
fionr srrr!¡cr\'¡nclrcrlirin oL¡rofthc publiccre ti)r lrsl(n!! Js dcsirc(.,.
()f coursc,bce¡Lrse of the cn)oti()lirlcdsisof clirr¡cc or r.lc¡rthof .r
sl)()usc. it is ¡rlrrclcrrt
to \'.¡it (sooclinrcs¡ lc¡r or rn()rc)bctirrerrn-
dcrtrking sLrfgcf\'.
.\ll p.tticnts\ llltilq t() |xrk "lrettcr th¡n I cvcl l<xrkcd"¡rls¡rr'¡:
qtrirc rr lcnqthvdiscLrssion of reirlisticerpcctirtions.
334 Combined Approach6 and Srne¡sisric Pccdrc

Patients who havefoetuted.on one q.reaand have already decided they

want a specificprocedurc,suchas"lower eyelids."
5 . Patientswith an enactliwit on wbat thry cen rpend ard want to know
how to gct the most effect for tlut expenditure.

For groups I, 4, and 5, almostany good techniqueis appropriate.llowever,

patients who want to look thei! vcry bcst (idcal facial proportions and con-
tours a[d/or rejuvenationthat is harmoniousand natural) reqttiletbt best0f
onr d.erthetictente,tkilk, and.wryical ju.dgment;it is m rhesepaticnts that this
chapteris dedicatcd.

FACIAL RBJUVBNATION VERSUS FACIAL

RECONTOURING
Aftcr thc patient'sspccificrequcstis understood,the ¡rcxt decisionthe sur-
gcon must make is whether the patient requiresfacialrecontouringor facial
rcjuvenation(or both). Thc diflcrcncein thcseconceptsis significantand im-
portant.Facialrojuverreri|nispcrformcdto restor€facialfcamrcsto thcirpre-
vious youthful look. Fscial recontouriagis perforned to changeor enhance
thc prescntfeaturcsto makethcm "better than thcy evcr looked." In othcr
words, facial rejuvcnation is rhe rexoring of bcq,ttt! (flr ttoTrren)or of attrac-
tivenett (flr ,rren). Facial rccontouring is the tedtion of beau.tyot attractive-
z¿¡¡.Theseare, to some degrec,wo separatcskill scts.It is challengingto
bring about naturallyharnoniousrejuvcnation,but it is cvenmorc difncult to
crcatebcautywhcrc therc is little or nonc.

Facialrejuvcnationrequircs:
L An old photo
2. An understandingofwhat the patientlikcsin thc old photo
3. An unde¡standingof t}le naturalfcaturesofan attractivcyouthful face
(fullness,smoothnoss,
and./orharmory of thefaaturcs)
4. The surgicalsKllsnecessary to obtail thesegoals
5. An understandingofthe limitation ofone's surgicaltechniqucs
Fig, l0-l is an examplcoffacial rejuvenatioo,the restoringofbeaury

Facialrecontouringis for the paticnt who is williog to rish loohitq dffirent

then he0r th¿ererlllhed (Fi,g.I0-2).It requires:
l. An understanding of aestheticideal proportiols and co͡tours (for thc
patient'scthnic group)
2. A perceptionof dre areaswherethe paticut'sfaceva¡iesftom thc ideal
3. A visionofwhat might be possiblc
4. Good communicationwith the patient to understa¡dwhich parts of
this vision dre patientlikcs and dislikes(we prcfcr to i[clude conserva-
tive computerimaging)
 'I
h . S ! . c r g ! ! l I l L L l t i n n x h l1 - r . i r ln . j L ^ c f ¡ n ú : l\Luii,g l¡ ALI ti)g!¡hcr 335

'l'hc
5. surgconnrusthdrc thc ebilit-\,torhinl<thr'ccclincnsion¡ll-v-ultlil<.e
p¡intio!!, brrt similrr-to sculptinglith cl¡,virnd bcing rble to idd ¡n(1
sLrbtrrct
ó . The srrrgicirlskillsto rcconrplishthis rision ¡ntl ¡ knowlcdeteof his or
her lintit¡tions

ljlc. l0 2

'l'his
paticntdcmorrstr¡tcshc¡\\bc;[rñ'cln be creirtcd\\,ith t'icill rccontorrri g.
Shc is shr¡rvnpleopefiltiYel\r
rnd;1 vctrs post{4)cf¡ti\ch'.
i,Ídl r'.1 \,',!1,...'ll\.,r¡t\Lr'.rq{r. ll, L, J. (1

KNOWLEDGE OF IDEAL FACIAL PROPORTIONS

AND CONTOURS
l-conrrrclo d¡ \'inci r'.rsonc ofthe first Pc<lplctr¡ unclclstirncl irntl clcscr'ibc
icle
.rl f.rci.rlpropoltiorrs.Stuclvinghis rvorl<.rn(1 that ()l ()rhcfsor1this srrbjcct¡rru
\i(lcs ¡ hclplill backgr'otrndrnrl is ir |crltrircrucntfi¡ licill rcsthctic srrrlicrv,
but this intirlnr¡tion is onlv.r "nrcnt¡l knorvleclge"lntil ¡ sllrqconc.rn(lrir\\ ..
rvcll-¡rr'<4lrrriorrccl (il gcncic) fircc1i{)nrnlcn1cll'!. i¡ both fiort¡l ;rn,.i¡rlolilc
ricls. This ¡bili¡v nr¡kcsir so much c.lsicrt() sLrrqicrlly cr'c¡te.firr cr.lntplc,irrr
.rtlrilcti\'cn()sc!li¡rs.rncl chin th¡t ¡rc in h¡r'nro¡iouspf(4rortio¡ t() circhothcr
rrnclbell clistinctl\,Inirsculinc()r'lcnririnc chirr'¡ctoislics.Such ¡ c()ursc()11
rllirlilg thc lrtrnrenfircc(rnd lrodr')shoLrhbc lrileblc rs.r night cl:rss.rtloc:rl
collcscsor ¡rt sclt)ols¡nd is wcll \'(r-lh thc tinlc inrcstc¡.|¡¡rl thc snl¡ll c()st.
'l
his shoultl bc.r p¡r¡ ol-ocll Pl:rsticslrrltcrrrcsirlcr)cr. t:\'cnm(n'chclplul is rr
c()Llfsc in sc!lll)tir1g.

It is rrot ¡cccss¡¡r' to h¡r'c ¡rrr'¡¡ tistic ¡¡lcrl t<)bcncfit fi()rn rhcsccor¡rscs.fhc

s()rl is () nrrkc sutr.tc()ns bcttcr irl pc,cci\inq Nh¡t rhcYscc. Until (rrc trics t{)
rlr.rkc¡ l.rcc liorrr cl.rv,thcrc irc llul(lrc(l\ ()f in)l)r)ftiurlfici¡l cll¡l¡ctclisties
thxf cscilpc¡lfcntion. Fl()$'krng shoLrldlhc oppcf lip L)c¡H()w \vi(lc¡ FI()\\'
thicl(¡ H{)\\ flr rrn¡c|ir¡lyslroLrlcl it l)r'()tfudcrclittirc l() lllc n¡s¡l tip iut!i chirli
A sufgc()nwh() thinks hc ol shc ¡ndclst¡¡rtlstlrc iclc¡lsh¡|c ir¡r(lpr()l)(n1i()n ()f'
¡¡r.lttr¡atitc nr¡lc iÜlll f¡rrr¡lc nosc shouLl tr\' nr¡king (nlc ()ut ()fcl¡vl ()ncc
this is nrrsrcrc(1,()ncsltxr[1 trv to bLril.]lionr cl¡y rrr ¡11¡ctivc f¡ac .rr()uncl !hc
n()sc.If cirr bc lcrv hunrbling,l¡ut c|c¡tcs i "rcirch¡l)lcnr()nrcrrt" thc slrr
qc(nrl..¡iusiDst¡ntN ¡r'cncssol thc Dcc(ll() knorr'¡ll t lrosclirciirl|cl.rtiorrshi¡rs
.rntlprolxrrtionsthet hc r¡ slrch¡s ¡lrr.¡r'sscc¡r.lrt¡t rrcrcrlilh Pc¡ccircrl.

Scrrlptilg rith ch\.is vcrv much likc lircirl srrrlicrv.Ilcing ¡blc ro tekc ¡rr'¡v
clly rvith r \r'irc l()(4)is likc rcc|rcinglr lrronrincnfjorr'lrviLhli¡rostrction;.rncl
n(^v bv nricr()lit gllfiirrq rrc cirn ¡clti "cl¡r," (1irr crirr1]yrlc.
t().r!¡$¡rcDt 1hc
chcek lronc or-chin ).

To unclcrst¡nciirliing,,\r'c rllrs¡ firs¡ bc irw¡rc of thc chilr¡ctefislies ()f rhe ilt

tfilcti\c, y()uthfirlticc. lVlostolthcsc lc¡tr.rrcs to us, bLll fhc (lc
erc \\'cllI(n()\lJn
t¡ils ofthe Pcriorbit.rl¡rc¡ l)crr rcpc¡til)gl)ecirusc ()ithcir imp()rtir¡rcc irslio.rls
'ltssicf,
fbr o¡rtinrrl, orrtnr.rl'l(x)kinq rcjncn.rti()rr. rllc flth!r'ol criuli()fici.r¡
sLUqerv, stitcd that. phikrsr4rhic.rllr',
cr¡¡li(r.rciirlsu|gcrv is ar'últar'r'rrí'rr.Ars-
¡hetic fici¡l surgcr-\'shrlrcs roots \\'ith, lnd is in s()mcrr,ir\,s illl c\fcnsion ol,
clrnirfici.rl sLrrrtcly.
 l l , . \ r n . r s \ , ) t ¡ l u 1 . , \ 1 . , 11 i . , . . ,l1{ c t r , . n . ' r i l i ¡ I \ , r u ¡ 3 l r \ l l l , , s . t l ' ( ¡

'l
hc ch¡r¡ctcristicsof thc r outhlirl l.rcci¡c[rtlc:
L l l h r l r ¡ t r \ ( ) r ¡ t h l i rhl c i g h t ,i n t h i sc . r s c( l : i g . l 0 . 3 )2 2 r r n r . r b o r et h c
c¡nth.rllilre. ¡s r¡c¡srrrctill_()nr .l lil¡ sizc plroro. Il i! iltltü lñ,t lt) it.
or¡tti:ttltnt orrr t.itttoll)üttlt¡a ol brrn'Lti,¡ltt it tttnrt lt¡ttttltttt tnt tltt
trluaulttot ití1t vi¡tbl¡ l¡ctn,c¿¡t tltt lid L:¡tt¡¡it¡rl lltt []¡1Dt1 thnl¡ lhL ab'
tlrttt Lti¡ltt 0l tlh'ht'a'nl¡or¡ tl¡L ¡vli¡1. Irl othcl lr¡rtls. \c f(i1(lthc
Icighr ol thc L¡rrxr.rsits hcight .rlrorcthc ti¡rli sh¡tJr¡r ol tlrc li,:lJi¡Ll.
\\ herc\cr th,rt rrlar bc.
2 . l h c u ¡ r p c r ' l i t¡ln t l i r f i . r b r o r r¡ r c ¡ i n r o r l h . l f c f i r l i .n ( ) l l J . r ¡t ¡ r s u n l < c . . .
l ) c s p i t ct h i si i r l l n c s s\ o. u t h J i r ul p ¡ c f l i ( l s( l ( )n ( ) t¡ l ) l ) e r rl o h . u c h ¡ ! . sb t
L . . t r \ 'l rl r l : i f\ l i r ) i \ t . r . r .l l r l JL . l . r \ t i \
i . I l r c s L r p c r i rtr¡ r s ¡ l l i r l d i s o n l v ( ¡ t r ¡ l { ) n r n r l l - ¡ r n trh c l i r l n r . u r ¡ r li n
\ 1 ) L r r \L(l) r l i c n¡ n ( l r r r c r r .
{ . I h c l , r l c r ' 1 r , r1r i r r ' g i rsrl r o r r l ,c.ul t r l . r ( ) stsh c i r i s . r t. t p ¡ r ' o r r r r r . r t tcl lrrc
t ¡ r 7 o ' c l o t l <g r o s i t i o r r' .¡r l c lrrr i l l i t h c k r r v c ¡i n v o u l h u n l c \ \ t h c i r r l ¡ f i (
¡ r ' h i t ¡ lI i | r r( , r l l ] c e n l i r cn r l l ¡ f c ( ) r r r l ) l ci s\ l r r p o P l . r s t i e .
5 . l h c . r ¡ p . r r - c nv tc n i c ¡ ll r c r q h ¡t r l t l r c k x v c ¡l i L ls h o L r lbt lc o r r h ( r I o l l n r r .
¡ r r r l t h c l i t l ( h c c l i j L r r r . l i ( )snl r r ¡ r l dL r ci n r l i s t i n c t :h . r ti r . t h c k l r c r ' l i i l
r u r r cr lh c c l is l r o r [ ] b l c r r tiln r ¡ c l e c ¡ t i h l vi n l ( )c . r ( h( ) t h c r .

fl(i. l0 3

E r o w sa l y o u l h l Lhnc O h l
1 2 2n r ma b o v e . ¡ n l l r ¡ L ¡ e )

B r o , i d( ¡ l n n n ) e ¡ p ¡ f s c o l
rnoolh skLnvLSrbl.h.lw..n Nofo'ch!¡dúr howrl'¡.s

UFDorldir¡ffabrow ar.á
s lulb!llnhlrnd.aslc

No lcar lroüqh or c r e e k sa ¡ d n rd c h e c k sl L l
( árk. rces!nd.r eyos

L o w e r l d ss h ó r rv e n r c a l l y t r p p . rl D s s h ó n r e v . a t r i l l
( 6 a m m ) w r l hú d s l r ¡ c l
rd.he.k idnclon

F a c ' ¡ l s k i nr sl i C l r lc a s rc .
a.d wrthoulwr.k es or
p g¡re.l spols

s r r o o l hw l h n o n o l c hn g
J¿\r Ino rs.r sD no lowls
Neck rs smóor¡ a¡d l'!hl

OF THE YOUTHFULFACE
CHARACTERISTICS
338 Coñbincd Apptu¡ch.s an.l Sync.gi$ic l()ccdu.cs

Atrophyof orbitalal;úpp€rlid
Frow¡ll¡esdeveop becomes su¡ken(gaunl)and
Browsbecomeptoi c concealsmuchredundanl skn

7 mm (64e¿)
d€creasen skin Darkcúclesof owereyeld
vlsblebetweenbrowand id ff€ase causedby shadowsand

showof prelarsáskñ
Increased
Wth atrophyot periorbilalal,
T€mpl€s
sunken lowereyel¡dbagsa¡e ess

Crowsleel wr nklesappear Alrophyanddesce¡toJmaar

L d-cheek lal rev6as toarlroughañd
iuñclon becomes
disrncr
Apparent
heighlof owerlid s lensthened Afophyol m dcheekfalmakes
tfom7 ñr¡ lo t6 rnrñ(230%)
cheeksbonyandgaunl;
Afophyol pe¡iorafal increases
vlslblityol upperliplurows kusáe) Lipsbecomolhin,wr nkled,
a¡d cáusesneg! ar dep¡essions
and nesaroundiowerlp
Plosisofskinárou¡dmandiblr
ar
Facialskins lax,er¡pty ¡gamenlcausesnotchngol
mandibuar márgin,makng
Jows areprimarilyoososkn,
m¡nLma lál
Neckloosensandplalysma

PATTERN
GAUNTING OFAGING
Sé€ lh s pál€nls cáEápr6s€nl6lon oñ p 416.

Transvers€ linesdevelop
lo16h€ad
Lax¡lyoi lowerid marginá¡d
V€rticalrowñlin6sappear raleralcanlhallendonrnay
causesclofalshow afld/orlalera
Pross ol brow

prslarsalskin
hiddén
Wink ns andcÉpeychañges Darkcnces u¡dorsy€scaused
i n u p p elfd s k i n by shadowsa¡d dárkerskin

Crow'sj€etwrink6s deveop Softtisslreol cheeksidesdown,

revealnglearl¡oLghflatlening
Apparenl
veriicalheighl lhe malareminence, a¡d
ol owerlid ncreases acce¡iuatinglhe nasolab a lold
Ld cheekjLncron
bocom€s
dislincl
[4idcheeks
ema¡nful especially
[¡alatslacasrcove to ¡asolablalold
adjacenl

Fac¡alskinoosens,wrinkes Nasoaba rolddeep€is

andpigmgñlspolsdeveop Deeperwr nkes 01!pper p (rusae)
Plot. ñidcheeklat fieat€sjowls; Mario¡elteInesappear
iawlneb€comesindislncl
Neckskn loosensandplatysma

I\IOSTCOI\,1I\¡ON
PATTERN
OF AGING
 The Synergyof MuhimodalFiciil Relvenarion:Puttins lr All Togérher

UNDERSTANDING THB VISIBLE CIIANGES

OF FACIAL AGING
Broadlyspeaking,there are two patternsoffacial aging,asrepresentedby the
two patients shown in Figs. I 0-4 and I0-5 . Witb fhe geurrting panern of a¿-
in¿ fat ofthe periorbital,temple,malar,midcheek,andperioralareasbecomes
atrophicdespitcnormal weight, and laxity and wrinkling ofthe skin develop.
Withthe mottclrnrnlnpqttern 0faBinB,the facerctairs fullnessbut soft tissues
becomeptotic, and laxity and wrinkling of thc skin develop.Signsthat can-
zrtbe treated by facelift, brow lift, blepharoplasty,and rhinoplury te lzbeled
in red.'lhe aestheticplastic surgeonshould bccome so familiar with thesc two
patternsof ag,ingtiat he or shc can prcdict how a personlooked 20 o¡ 30
yearsago, beficreevenseeingan old photo. Thc facialagingprocessis not just
th€ ¡elcntlcssrelaxationand southwardmovemcntofskin andsoft tissuein rc-
sponseto graüty, though this is usually an important factor. Rather, it is a
complcxrcsult of bony changcs,hereditaryfactors,sun damagc,fixatingliga-
ments that often yield (such as the lateral canthal tendon), and those that of-
ten relaxless(suchasthe modcolusand thc mandibularligament).The cxccl-
lent work of lambros compariugsuperimposcd imagcsofaging facesovcr sev-
cral yearsis well worth studying,

Changes Most Common to All Patterns of Aging

Forehead
t . Transversc wrinklescauscdby frontalismusclcactivity
2 . Verticalor obliqueglabellarfrownlinesandñlrrowscausedby corrugator
muscleaction,

Frequendy Seen Features in the Most Common

Pattern of Aging
Peüorütal Area (Fig. f 0-5)
I. Browptosis
2. Ptosis
ofinfrabrow
softtissues
3. Wrinkling and crépcychangesin upperand lowc¡ lid skin causedby orbic-
ularisoculi actiüty (squintingand smiling)
4. C¡ow's-fectwrinklesand oblique wrinklesradiatingout f¡om the o¡bit to
the lateralforehead,templcs,and checksresultingfrom orbicularisoculi
action(seeFig. 10-5)
5 , Upper and lower eyelidbags
6 . Hoodhg ofthe late¡alupperlid
 340 Conbi¡€d Approách.s dd Syners¡tic Prccdurcs

7 . Dark circlesunder eyescausedby:

. Shadowsftom overhanging eyeüd bags
. Dark skin resulting ftom actual h)?erpigmentation or the dermal ve-
nous plcxus showing duough thc thin, translucentlower lid skin
. The shadowsa¡e deeperand darker ifthc sulken areaoftear-trough de
formity is prcsent.
8 . Auophy and desccnt of the malar fat causesseveralchangesin the peri-
orbital arca:
. As the thickcr malarf¿t dcscends from the inferior orbital rim, it leavesa
sunkcn clescent covered with only a thin layer of skin and orbicula¡is
oculi (the tcar uough).
. The obliqlre low bony area (called the malnr-facial groove by Mendef
son) bctwccn thc malar cminencc and the edge ofthe piriform aperture
is revcalcd asthc malar fat atrophics or slides down into the midcheck.
(This areais lighdy shadcdand outlined in Figs. l0-4 and l0-5.)
. The lid-chcckjunction becomcsdistinct.
. The apparentverticalheight ofthe lower lid increases twofold o¡ more
asthc malarfat descends.

Malar and Mid¿he¿hAreas

I. Dcscentand/or atrophyofmalarfat causcs:
. Flafteningofthe malarcminence
. Exaggcration ofthe nasolabial
fold
2 . Descentof midcheckfat and skin causcsjowls to develop.
3 . Facialskin loosensand ingrainedwrinklesappear.

Perioral Araa
l. loss ofbony heightofthe alvcolusofthc maxilla¿nd mandiblecangivean
edcntulousappcarancc.
2. Wrinklesand decpfurrows(rugae)dcvclopon the upper lip.
3. Nasolabialcreases decpcn,
4. The uppcr lip may lengtllcn.
5. Marionettelincsmay develop.
ó. Assortcdlinesand folds appeararound the corne¡softhe ¡routh and be-
twce[ the lip and chi¡.
7. The lips becomc drinner and atrophic.

-
 Thc Synergyof M hiñodd racialRcjuvcnátion:
lutting It All Toacthcr 341

Jnnline
I. Ptosisofthe chin pad develops.
2. Notching ofthe mandibular margin at the lateral chin is prescnt, also mak-
ing t}re chin look pointy. This notch is not a uuc bony notch bur is caused
by ptosis ofthe chin anterior to and ofthe jowls posterior to the mandibu-
lar ligament,which hasnot st¡etched.
3. The¡eis descentofthe iowls.
4. Bony resorption of the posterior surface of the ascendingrarnus of the
mandiblecauseslossofthc crispanglcofthe jaw (gonialangtc).
5. Submentalfatty depositscan hide thc margin of the mandible,especially
posteriorly,makingit indistinguishable from the neck.

Neck
l. Skin redundancydevelops.
2. Submentalfat develops.
3. Platysmalbandsdcvelop.
4. Subplatysmalfat depositsmay appearor enlargc.
5. Submaxillarysalivaryglandsmay becomeptotic,

Changes Unique to the Gaunting Pattern of Aging

(seeFig.l0-4)
Atrophy offatty tissuescausingsrurkenappearancc
of
o The temples
. The uppereyelids
. Midchcck
. Malar facialgrooves
. The perioral area(causingdeprcssionsbelow the lips a¡d around the
commissures);¡csult is a gaunt, unhealthylook (rcminisccntof ad-
vancedHIV lipoatrophy),oudinc ofskull almostvisiblcthrough skin

The atroplryof fat iri the upper lid ar,d inf¡abrowhas an unexpectcdeffect,
pointedout independendy by Colemanand Lamb¡os.This wasmy (T,L.R III)
first epiphany or "aha" otontenti\ u\dcrstanding facial aesthctics.Becausewe
subconsciously judge the hcight ofthc brow asits distanccabovcthe upper lid
creáse,any changein the location of the lid c¡easeor sulcusaft'ectsour per-
ceDtionofthe brow's position.
342 (,rll,ii,\1.\Jt!r,,.he\ nl s\.crqisti. 1'.¡¡r(]lr\

l,t(i.t0 6

I n t l r cr o u t h l u l l . r e ci n l i i g . l 0 l . - , 1r.¡ c . r s r ¡ r c n r c( ¡) rl rth c l ) r ( ) \ \t ¡ )t h c r f c ¡ s ci n
r I i l . r - s i z¡ch o t o r v o u l dr c \ c i r il r h c i ¡ l l r ot l I I n r n r( s c cI : i g . l 0 6 . , , 1 ) .l h c s h r ¡ l
of prct.rrs.rl skin is onh .l nrnr. li! .llc 59 (scc lrig. l0- 1. B). l hc lrur .rp¡c:rrs
trr lr.rrc tiro|¡rcd tir.rrrrrticirllr', rith ir lrcighr ol onlv 4 r¡rl ¡bovc thc sulcr,.
( s c cl r i g . I 0 l : . 1 l ) , : r l c c r - c r socl 7 r r r r ( ) f ó ; l %l l o n r t h c l o u t l r l i r l I I n i r n .l l u t
( ) u r c y c sr r c l ) h ! i n ! , l f i c k sr ) n u s .l l \ \ c t ¡ k c i l n l o r ' cr c l i r b l cl ¡ l s e l i n ct r ) n l c n s l r r c
l ) f ( , \ \h c i q h t ,t h c i n t c f c . l n t h ¡Ili n c ,r c l i n t l i n v ( , u t hh c f b r ¡ s r r ' . rrst 2 2 n r n r
¡ n t l l r v ¡ l . l c5 9 l r . r sd r r r ¡ r ¡ c do n l v 2 r r r r r .r , r l 0 ' 1 , l i c i ¡ r g . l r: 0 r r r n . r b ( ^ c t h ú
c ¡ D t h r lI i r r . ¡ r u rc r f o r i n p c r c c i | i n et ¡ n )n r u ( l )( l r ¡ r p{ r l r l r c b r ( ^ \ ( ) . . u f f c ( ll ) c
c¡Lrscth! ¡lr()phr ol thc |criorhit.rl .)r)(liDli¡l)r{^\ lit h.rr |cvc.rlcdthc ¡rcri.
oL¡slo r b s c L ¡ r cst u l p c r i ( )(fn - l ) i t .irnl r . \ \ i l h ( ) n l \ ' - 1n r n ro l s k i n v i s i b l cb c t r c c n
thc inr xn(l thc lrlr¡r. lhc tit rtlr4rlrr h¡s ¡lso c¡Lrscrl9 rrrrrrrf ¡r-etrr-sitl slirn
to LrcrisiLrlc.slrilirrrgthc l('cxti()nr)l thc .rl)l)¡rcntli(l crc.lse()r sulcLrs Lrl)\'¡r(l
. t r
[ r r ' 5 n r n r( . r ni n c r c ¡ s co 12 2 5 %n l o f cl h r n t h c \ ' ( ) u l l r l u l n r n r ) .l ) c r h ¡ p st l ] i sc \
ilgqcr¡lcd l)cfccl)li()rr ofbrorv ¡rtosisis \'lr\ \\'r tcn(1c(lto pl.rccthc Irrrrrvs¡xr
h i g l ri r rt l r c c . r ' l vt l . r l so l b r o r vl i l i .

'l
hc p.rticnrin Iri¡ls.l 0 -l ¡ntl l0 ll rcl)rc\cnl\.r(()nn()n fitnr ()l .rgingkn(^vn
r \ . 4 / r r ¡ i ¡ r l ( s c c . rI u l l c . r s cp r c s c n t . r t i ¡{)'rl rt h i \ p : r t i e not n p ¡ - l l ó + 1 7 ) . H c r
f . r c cr ¡ s l i r l l i n v o L r t hl s e cF i g . l 0 . 3 1¡,n t l ¡ t r { c 5 9 s h cr r . r si n c \ c c l l c n lh c . r l r l r ,
licc ol .rllrlisc.rscs inclurlineHl\',.rt irlc¡l Lrorlrrvcight,¡nrl lr¡d Lrrtlcrqoncno
¡rlcvirruslicill sLrrl¡ctr.Irt ¡dditir¡r to thc usuilllil\i¡\, irr(l ptosisol tlrc soli tis
srrcs,hcI li.c (lcnr()nstr-r¡ctl ¡ no¡icc¡blctlcgrec()f ¡tr()ph\'()11it (rrrt1possiblv
s()Irlcnrusclc.rlrrl)lr\')inthc rcnr¡lc. pcriolbitrl, nrlhr, mirlclrccl(.irr(l pcri()frl
irfcirs.This q.r\c lrcI fiec ¡rr un.rttr'.rclivc..4drr¡ /oolt,aud tltL'aut/íuttl tlr tl:t/l
.arll tliuo!t ltt tr'ttt tltrott¡lt tltt shitt.

'I-his
g.runting, ¡oscsrpe.ixlproblcnrsirl l h c p e r i ( ) f b i t ¡i rl f c ¡ . _ l h cs L r n k crrrr¡ p c r
l i . i r , ¡ r r i r i . . r , i i l l c r ' . n t i , r , i i . ' r : n , ' . il... it rtlr4rhr'ofpcriorl)it¡l lil li()nr this
()l
l n t t i t ! ¡ 1 n l ¿ ! ! 1 t t t o ¡ l / / l ? f i r . I l l ) q . r)r is it thc rcsrrlf blnt0t dLh¡!.¿tlct
( F i g .l 0 7 ) )
 Thc Syn€rgyofMultimod¿l Facial Rejuyemrio¡: Ptrtring k A1l Tog€rher 343

FIG. 10-7

Sunken upper lid causedby levator dehiscence.This patient,shownar left

in her normal¡elaxedappearance, hassunkenupperlids and trte ptosisofthe
upper lid margins.The lid marginpartiallycoversthe pupil; the brow position
is only slightlyhigherthan no¡mal.On the riglrt, a maximaleffbrt to opcn her
eyesresultsin the classicsignsof levatordehisccnce: ( I ) persiste
nt ptosisof ti.rc
upper lids (though lessthan in Fig. l0-7), (2) multiple decp tr.ansvcrsc fbrc-
headwrinldescausedby extr€mechrodc contractionof the frontalismuscles
in trying to lift the upper lid, (3) a resultantexcessivelyhigh brow position,
and (4) a sunkenupperlid (seeFig. 10-9, ,4 and 3).

Sunken upper lid caused by the gau¡ting

pattem of aging. As describcdon p. 342, the
upper lid position ar'¡dfunction are normal i¡
this patient,but atrophyofthe infrabrow and
periorbirali¿t causes a dark.surrkenareajurr
under the brow, giving the illusionofa signifi
cantdrop ofthe brows.Contrastthis low brow
position with the overelevatedbrows in Fig.
l0-7. B, ¡nd rheditferen¡ial di.rglorisis easy.
341 CoDbiDcdApprur.hesrnrl S!¡(rgisric f ro.cdrrcr

FIG, IO 9

rnracir6valor
áponeuros¡s(purpte)
n€e s ¡ntoid creáseañdrarsal
plare,fetracting
Ihesk¡ñw¡lh O musclecontracls
lhe ld whenrh66yeis open

^ Lid s l¡lt6dbythéexlension
12) ol lsvatormu$te (Múlorb
muscre) ¡ntorarsalptal€
Fronlatismuscte
¡s€nioi 16 axed)
I
positioñ
Normarb¡ow

Orbilálsept!m

Fuiluppor d
Ld creasecreatedby
evarorns0rlio¡inroskin

- t¡tenot rccius ñuscte

V.

Capsulopalpeb¡ál
lascra

NOF]IVAL
OPENUPPERLID

I¡ thc n(r'n)il uppcf ¡id, thc lcvirt()raponeurosis is rhin bur stro¡tg.Ir iiits t¡.¡c
litl.quiclly and fi¡r.rn cxrenrlcclpcri<xl,l,ith no co¡tsciouscflirrt b,vthc inctr-
vidu¡I. In rhc g¡unling pattcrn of lging,:rrrophv ofrlrc infialrftr$,anclpcr.ior_
bit¡l iir¡cirnrcsultin ¡ srrnkcuuppcr licl.lVirh lossof firrvolunc i¡r fiont-ofrncl
behind rlrc orbitirlscprurn!!hc ¡rc¡¡of rhe clctitl l¡bclcclfirll up¡rcrlitl reccdes
posteriorlyundcr the su¡reriororbit¡l ¡.inl.This ¡tot onlr, {ivcs ¡ sr¡nken¡p-
II
pcirf¡ncc,bLLrlrlsosiuniticirnrbrorv ¡rtosis(scc Fie. l0-.1). II
I
I
I

t_
 Ih. sr.crq .l llu ¡úrr)dn L.,.nt Rcin.cr.ri,r: t\rrjng It Ali T()gcrtrcl
345

TIh s r e s u l l sr e x r ¿ h r g h
T f¡ ggers
résponse to ¡atsebrow
@ ¡n áliemptlo
iO b,*p.";";;";d;; lrep raise d
o v e r ptúo t t h ei r o ¡ r a i s

Orbita Felracted Levator

sepl!ñ perorbrra t¿t Tri9ge6
apone!¡osrs
@)ra¡seihe résponseto
lpper eye d
s c PF q r . 7 3
I

I (!) conlract¡on
n*urr rg n dtaxima
of evaror

i3
Excepró.attyw de expanse ot
skinslretched
rhinryovertronla
ooneandsúpenoró¡blat riñ ll
-¡\
Deepsunke¡uppertidtrom
p! lo' thelevator
ercessrve

Bolhlhe levatoráponeuross Becarsodehscedtevaror

|l_l andIhelevatormusco are (6) s ñowonlyallachedlo
deh¡sced
or extremety stretched r¡e aperor thesk n lod
andcan¡otr!tly ráiseupper¡d ? , t h es k ¡ l o d i s r e r r a c t e d
póslero¡ntotheorbit
crear¡gsunken¡dand
p u [n 9l h ep 0 r ¡ o f b l a ]
(r) Plolicuppe¡ld cov€rsihe pupi
causingblockage ot ltre

Capsllopapebra táscia

HOWLEVATOF
DEHISCENCE
CANCAUSESUNKEN
UPPERLID

1hr'plinr.rry pirth()logvin this conclitionis dchisccrrccol,

crlrcDtc thinnitru
of lhc le\'i1t()r.ip()ncu11rsis,
pcr-ntittingthc litl nt.rr-gint() dr(x)P .rD(j
frftixlly
covcr the pr¡pil (scclebclctlbox ) abovc,¿nd iirll.rv rhc scc¡trcrcc,rro.,,r,1
tl _
illrrstr.rtion).
Á clinic.rlerenr¡rlcofthis is shown in fig. l0 7.
316 ! {rli,!.r \ff1.'(,(..,¡l(. r ' ' L i . r i .I ' " f , 1 , ( .

\Vhcrrrhc su¡ken lirl is ciruscdbv lcv¡tor tlchisccnccrhe .r¡ronct¡rosis ofthc Ic

\'¡t()ris e\trcrrch thinned.rsit ¡tt¡chcs !o rhc tlrsll plirte,irllo$i¡g, thc Iirl nrirr
gin to tlr<x4r.Thc secontl¡rl inscr¡ir¡rrf-thc ryoneur'osisirlt() thc r¡¡l)er lid
sliin (rhiclr crc¡tcsthe u¡rpcrtirrsirlli)ld)rcn).rinsrcl¡titch intirct.As thc lcr'¡
l()r c()utr'¡cts cvcr Dlorepostc[i()flvir] ¡n irtfc¡)rptto r'aiscthc lirl, tllc lirl crcirsc
irrd its irssoci¡tcdskin irntl ¡rcriorbitirlfirrrlc pullcclpro¡¡rcssivcllfirrthcr brck
runr.lcrthc su¡rcr'ior-orbitll linr, crclting thc s.rnrcsunkenir¡r¡rcirrln(c. Llnlcssthc
plrlslicsurgc()nhxscxtcnsi!cc\l)cricnccwilh lcvirtorrcpirir',r'c rc(()nrnrcr(lrc
fcrring thc p.lticntto.ur ocrrl()l)l.rsfic sulgcon lirr-thisrepirir,bo¡ ¡ot tlltil ó trr
l2 ¡rr¡r¡lls ¿t¡cr¡ll :rcsthcti.snrr¡crvh.rsbccn conrplcted.fir trlo r'c.rso¡rs:
l. In ¡hc bcsr of h¡ncjs,lcv¡¡r¡ rcP.ri¡is.¡n inrprcciscs(icnccrltrl fc(lr¡ircl,
rcvisioni¡.lt lcast20% ()fciscs. lf dlc rcst olthc rcjuvcn.rtirrn is rrc:rr'lr'
l)crt¡ct ¡nd r lc\':rtorrcPrir-is .rlsoPcrlirfnrcd,if thc liti ¡rositi()nis Dot
pclt¡ct, thc p.rticDt\rill bc unlr;r¡r¡rlrrith thc cntilc surgicirlcllirt.
2. Ifthc lclrrol rcp.riris pcrt<rrnrcd lirst, lnl srrLrscr¡rcnt
¡cslhclicslrgcrr
()n thc rrfpcr lid rrns thc risl( ol rrpscltingrhc (lclicillc b¡l¡llcc rll¡t
l r , ' l , l 't l r r 'l i . l i r ri r \ ( ( ' r I C ( t L .fJi , \ r l i , ) n .

l{cgrrlrllcssofthc cirLrsc,tLt trultn tppLr lil lLais to n stcutitt¡h, ¡nrullarictrl

nltl !tlut t;r;!trtri sitrnrhz: AIthoLr¡r,h not visitrlc,¡hc rctf.lcti()n()l tltc ti¡rl)c
hirtrl rhc sulTcliororti¡irl ¡i¡n usu,rllvconcc¡ls¡ fii¡lv Irrlgc.rnrountol-r'ctiLrrr
,.i¿ntskir¡.It t¡kcs t\\'()t() tlrrcc t¡¡ncsnrrrrcskin to f<rlkrrrthc lit l¡.¡ck.r ccr¡
tinrctcr int() lllc (nl)irirlrcccss.t¡rtlthcn l)¡ck ()or ilgiritr,c(nl[)Jrcrl \\itl¡ thc
¡r¡oLrnt ol skin nccdcdt() c()nrcstr¡i!,ht (l(^\¡r fionr thc rubit¡l rinr tr¡ thc licj
clcirsc. f hc|cfiric. il tlr ttruhn ttl)l)t1lt.ri01hi! a l .ljrt ^ rL'!t0rú l^' li t .¡rn.li i¡t.tt,
this crecssrki¡ rvill no longcr bc trkcn rr¡r[r1its joLrrno into thc orhit .rrrl r ill
erci¡tcir rc(lurr(l¡ncythat nccds¡r bc crcisccl.

TRADITIONAT MODALITIES FOR TREATING

AGING CHANGES
'lhc
"lli¡:, I_our"procctlulcsoftr.rtlitioD¡l¡csthcricfici¡l surqcrvirralü(lc[)r{^\
liti, blcph.rlo¡rl.rsLv,
ficc liti, ¡nt1rhin()pl¡sr\.

Brow Lift
Hitvitr¡¡rrsccltllc ()pclr c()r()nirlbrrxr'lilr iirr m()rc thin l5 vcirrs,rhcn I
( l.l,.l{. III) fccdlle(l¡n(l studicdr l¡r!¡c nLrnrLrcr ofmv prticrrts.I firLrrrdthirt
tlcs¡ritcgrxrtl clinicrl r-csults,35% ol r¡r' olút raroualpat¡t tr st¡rc(l ¡ltitt rltcv
"lrrukl ncvcl do it rglin" i¡rrd20% sii¡.l"thc\'\()uld ncvcr-r'cconr¡rcnr1 it ro
¡ tiicnri." l{cirst¡rsi¡chrclctlencs¡lrcsi¡¡n(l p¡rcsthcsi.rs (cs¡cci¡llv irching,l;
2.3'/u scrc rcntpor':rrtlntl l9% r'crc ¡crsistcnt.l¡stinq u¡ ro 5 vcirr's. No cnt|r
r . r ' l r i i f . r t i c ¡ r t lsl . r . Il ' c r . i s t c r lr\tl i ' (s t l r (\ i . l s .
 'lh.s\¡r,g\
i,t.\l!li¡r¡l.rl Ii.i.¡l l{ciu1(r¡rn¡r:I'uril.sIt.\It()g(rhef

In contrrrsr,97% ot rnr tsLopir [trol'-liJlprtl¡¡r¡rs:ridtho,rrr¡Lrltldo it:rc.lin.rr]d

93%,rroulcltccr¡¡rrrcntlit t() ir fi'ierld:ll% ofcorrrn¡l bror lifi p:rticntsconr
plirinetlof hirir krss¡¡tl scal visibilitr',comP¡r'ctlrrith <rnlv3% ofcrrrloscr4ric
pirticnts.lhr¡s \\'c ¡lranriuc¡.1cor(nril lrro\\'lifi in firrrr of thc cntloscr4ric.rl)-
pr().lch.\Vc Lrsefi\'c ports: :r nridlinc,¡ pilir ()f prfiln)c(liiul..rntl.r |lir of tcnr
poral incisions,c¡ch rb()LrtL6 crn lonq rrrtl crtclrding r¡tliitllv lr¡ck fiom rhc
h.rirlinc.'fhc¡.rrirnrcciiirn incisionis Lrc.r¡cr1 rlirccth ¡lrorc tlrc,ucl ltclc nr¡x
ir¡¡l clcv¡rion oftltc b¡t¡v is dcsir'c11usu¡lll lrtclrllr. l.)issccli()u is sub¡cli-
()stc¡lirrldc()fr!¡qill()rn rsclctcsccti(r1is rlortcin .rllclrscs, nrcticLrlousl\'.ry()id
irrg clclr'libcr ofthe sr¡l)r'¡tr()chlc.lr. strpr-:rorbit.rl,:rnrl
thc l:r¡cr¡lnrostbr¡nch
of tlrc sLrprirorbit.tlrlcr\r:s.Llnlcsse signiliclnt lr¡nsvcrsc.rcrsc ()f-(hc nirs.ll
rildi\ rcquircsir, r'c clo not r()rtincl\' fcscc(tllc l)r()(cr'usl¡us(lc. This clit¡ti
nirtcsl)lccding,li()rn thc nrLrlliplc\0fti(ill \.ciI]rith¡t fr¡r1thr()uqh fhc l)r'()ccrrrs.
[)út c\cn n]{)rcinrp(n't¡nt,it l)cr¡ritslcrrinq intir.t r 1.5 cnr r|idc sttip of ¡eri
ostcunrin thc nritllirrc,rr hicll hclpsitnchortIc nrctli¡l Irr'¡^rsrlorvn.Lrr¡iry()i¡.1s
r hcir {^ !fclcvJli{)n.Wc usct\ () l,;r(l()1irc(( irrrpl Srstcrns,Inc., l)¡lo Alto, ( lA )
fi\rlti()n(lcviccsinscrlctlthrorrth thc ¡.rr.rnrceli¡n
3.0 tut¡l .tLrsorLritLrlc incisior'..

Irl ot¡r l¡st 100 c¡scsrf crrtlrrscr4ric lrr'rxrlift thcrc l crc ¡o infi'cti()ns()r hcnr.r
l()nr.ls.n() pcrsislcrrLp¡fcstl)csi¡s,itn(l n() l)cfnt¡nc|][ l¡rir krss or eoDcc¡rrs
¡[lrrrt sc.rrs.In.rlrorrt5',?, rf ¡r.rricr)ts tl]c skin (^cf thc llt(l()linc (lcricr lrcc.tntc
scnsili\cl() t()ochbceirLrsc ol thc sh.rr'p ¡roi¡ts¡nri l¡srcrlu¡ to (r nronrhs,rr'lrcn
t h c t i ¡ c s r l i s y r l r c I. h ¡ r e l c ¡ r n c ds i n c ct h c n t l l ¡ t o n c c . r ni n j c c tI i d o c ¡ i n cr r i t h
cfincl)hrir)cint() ¡ scnsirivcilrc.lc.ll¡scdlr{ thc dc|icc irlicr.[ 11)6 |ll(n¡lhs,thcrr
gcnll! nr¡ss¡llcit to Lrrc¡kthc tircs ()fl thc lr¡sc ¡nrl ¡clicvcthcscsv¡rpt(nDs

Facc Lif't
Wc ellrxrscthc f¡ec lifi lcchniquc l).rscd()n lhc ¡n)()Lrr!()l l(xxc skit) in tl)c
ncck. lfsliin rcdunilrrnclis ttrorlcrittc.¡rrd fcsp()r1(ls \\'cll t() nrinlrirlclc\¡tir)rl
\\'ith ¡ \'clri..rl vccl(r-,\\'c Lrscrhc ^lA(lS liti. i\lrxlcntc [)hlvsnrtl b¡r¡ing i\
n()l ¡ c()ntriindiciti{rn.In !hcsccirscs. it sintLrllitncousitntcriorplirtvsntitr-c¡irr
is pcrfirr-nrctl rr irh llillrscationol .rtroLrt i0'/, ot thc r iLlthof tllc Drrrscl(,l)cl(^\'
()l
lhc ¡¡rglc thc rrcck.No dr-¡ins¡r'c rrscrl.rll rvountlslrc s¡rr.rvcd rrith IIcnro
sccllissucirdhcrcnt,.rncl¡rrcsstrrc is nr¡i¡t¡ilcd fi¡ 3 r¡inLrtcs.Wc clo rrot usc
rhc lhird sutrrc loo¡rof thc cttcnrlccl,\lACS lifi tirl scrcr¡l rc¡sr¡rr. Fir'r, tic
qncntly fllcrc is inirdcqLrittc nrielchcck soji tissLrc to g¡i¡ thc tlcsircdnr:tl¿rcrl
hrnccnrcrrr.Scconti.thc nrr.rn¡{c ()f¡r! tilciirlpitients is 59..rrrr1irt this lgc.
rhe rlrirll sutufc bLrrrchcs up thc l¡tcf¡l l(nvcl lid skin so rlruchth¡t ¡ skin crcr
sio¡ is rcquirc(l.usu¡llv 2 to.3 cnr long.rntl crtcn(iinq scvcritlnrillimctcrsbc
vond thc Irtcr.llcrnthus.A skio il(ision is othc¡rvisclo¡ rrcccssirrr', becluscrvc
r.rscthc ¡lirnsc()r'rjLrn(tir'itl
ir¡.)¡rr'oirch
li)f l()\\erlrleph¡rq)lilst).Ihis sil\.cslhc lri
ricr)i¡n rnncccss.lr!sc.rr'.rncl s.trcsthe srrtgc()n\cYcr'.¡l nlinutcspcr e\'c li)r cut
34¡9 I 'l .l\,1{ l ', 1' . , L - l'

'fot¡l
tilrg, herüostasis,¡nd sutlrfing. tirDefbr the lo\\'erfr.lrsconjLLnctl\Jrlbleph-
¡roplirstv\r'ith the CL). lasclis 3 to 4 ulirlLrtes pef clc (of zero ifno blephlro
plastl is ueccssarl,).Thir<l,bcc:ruscr1ltissucrrnclcrtcnsiorlLrnrlcrgoes the bi,
mcchenicalproccsskn()\ur ils ¿r?¿f (r'ciexationalong lircs of nirximal tcnsionl,
\\'c sllspcct (but hlvc no acadcmic prooi] that thc m¡1el erca rrrgrnentecl [-rv
nricrofirtgrefting uill st¡v in plecc iirr longcr thru tisslrcbroulifrt up bv thc
thifd sutufc loop. f¡¡¡l¡¡¡, if thc clcvited tissucis inirdeclurte, xLrtolo!:ous lrt
g,f¡ftingor-ln irrrpl¡ntwill still [rc lccluilctl.Llstlr,,irnvkxrsc pcfiofl]it¡l sl(inis
x)utinch tightcncd\vith l¡scl rcsLrrficinq, so ¡gii11,no lowcf Iitl sl<.in
crcisirn is
lcrlLrrl-cri.

Upper Blepharoplasty
llccauscrhc litl crcascin thc v<¡u¡hfirlliLl is 8 to l0 nrn fl'ornthc licl rrirlgin,
thc lo*cl li¡rl¡ ofthc rr¡r¡rclblcphiiloplirstvincisionshorrltlbc ¡i t{) l0 rrrrrl
fior,r thc lirl nliug,in(in nrcrtiuttl lrrnrcnl.

Fat rrnd MuscIcRescction

ljt(i. lo- t0

lLi¡elr'c|rcs¡ tirll lrlolr,nf¡f¡dignr shitt occlrr firr'cxpcricncedsrrrgcons,brrt

sr.rchir plelsure lv¡s oflir'cd irv l-¡qic¡ \'hc¡ he ¡rer'ccivecl thirt fhe rftr¡.livc,
!otrthfirl rrp¡rclcvclirldocs not h¡vc lcss firt th¡n the e!¡Lr¡)t b¡ggt oldcr evc
or
lirl. In f.rct, thc qrpcr lirl rnrl infi-atrrorvarc* rrc rluitc firll. but thcil skil is
f¡ut ¡ncl el¡stic.
 l l r . \ \ t r r r g ! ( ) f ¡ l \ ' i n , o ¡ r l f r ( i . r ll t . r r \ c n ¡ r i , i r l \ r i n g l t . \ l li,!.rr(. 349

FIG, IO ¡ I
i\dnrillc(ll\, thc l)r)tic br(^r c¡rr lrriltq c\cess
inf¡¡lrrow skin ¡nrl soli tissr¡cinto thc rr¡¡rer
cvcli(l¡fcl. Bur rr hcn this is lcpositioncrlln¡n
rL¡lli'oI sLrrqiciillr'. fhcfc is rxrclr c\ccsslil in
t l t c L ¡ f l ' c rl i ( l r ( \ ( ( l , t I l ) ( n r r ' , l i , lrll, r , i t r r r . J L r . r

Q t , ' , I , r s e T I r i r l r . r r r , i i S r' )h)r l i h , 1 I - . r { r c lrl , ,

su!,g,csl frfcl\' (n-ncvcr rcnr()\in!itit fi()nt fllc
(cntI¡l ()r l.rtcr¡lrrP|cr liil. but r.lrhcft() tLtckit
int() .1tiqhrcr \\r-Jl)l)crb\ rc¡t)(^ing skin ()nl\',
sinrilirft() rrhi1tis LLrlc in ¡ 1r¡11i1i()n.rl nr.lsl()
pc\r. We hirycbccrrriring this sinccit s irssrru
g,cstc(1, .r|rdNc t{rr.rllv.rgrc(. t'l)l)cr li(l lir his
bccn orerrcscctctilit dcc¡dcs,lc.rrinc clcs trxr
h ( ) l l ( \ ! .c s I c c i ¡ l l v¡ s l h c . r q i n qI r ' o c c srsr c c r r l s .

ljt(i. I0 t?

'l'hc
c()rl sh()Lrl(l [)c t() re\r()fc,lo thc c\tcnr p()ssiL)lc.
rhc litll L)rlrlir-nt.¡rpcrrr'
()l
incc \'()urh.f-rccpr lirr'thc nretli¡lp¡cl. lit is r'¡lcl! retD()\'c(l l|nlcssc\lrcn)c
ll rctlrrntl.rnt.llris is cs|cci¡lll trr¡ein rrrcn.in lhonr crccsssol-trissuclc¡¡or'.rl
c¡n f¡minize thc c\,clirl ()thcrrvisc,(nrl! skin is rc\cclcd (n() orlrictrl¡r'is oculi
I l l L r s (t c ) .
350 (irnbired^ppr)rdr(s,rn(lsrncrgisricfú)((drre\

Closu,re
Llnlcss:rl¡ter¡l c¡ntlr;rltcnclonsuspcnsion (dcscribedlrtcl in this cha¡rtcr)is trr
Lrc¡rcrf-<rrmcclfirr l l¡x lid rn:rrgin.thc skin is closeclit this point, using l ó'0
l)rolcnc running srrLrcr.rticul¡r sut!¡rc. l'his is gencr:rll1'lcfiin firr 5 to 7 cll1s,
but cir¡rbe lcf-tirsl<¡ngilsnccess¡f\, rr'ilh()!rtthc crossh¡tchingofinterrtrprctlor
fr.Illnilrgsuturcs,

l,ower Blcpharoplasty
jrrncrir'.rllos cr blcph.rlt4rhsq'-l his tcchnitluc .u oirls r sc:rr,
Wc ¡rrctlr rr-lLnscon
pr¡;r,iclcs
crccllcnt crprosrrrc, irnti s¡r'csscr,cr¡lnrinutcs(f (pcr¡tillq tinrc pcr
cvclirl.

(luttin!¡ is donc uirh tlrc (l(). lirscr-ti)cuscr.l

h.rndpiccc,r¡sinrlli \\'rtts irl thc
c(DtiDu()uslr'¡r'c nrodc, $'hiclr is c¡trickr¡rtl ¡lnxrst [rkxrllcss:Snr:rll\csscls
snr¡llcr¡h.r¡rI nrrr in cii¡nrc¡crc¡n lrc co.rqul.rtcd lrl r'.rising
onc's h.rnrlto dc
fircLrs thc bcirnr,crcirtingllcilt. An clcctroc¡utcrr unit is irlrr¡ts ¡t h¡¡tl in c¡sc
it Iirr'gcrr,cssclor'blccrline¡rtcrl is cncorrttcrctl.

IIcnlv ll:ulis, plof.:ssor'

of <4rhthalnroloqv¡r U(ll,A, ploreLl lonq x!¡()th¡r il
rrlnsconirrncrivllincisiortdocs not nccrlto l¡c closcrl.In fict, thcrc is.r hig,hcr'
qrirnul(Dr.rr.rtcNhcn it is cl()scd.

Rlrinoplasty
A cliscrrssi<¡nof lhinopl.tsrvtcchnirlucis lrcyonrlthc scopcof this chiryrrcr.
Wc
lou[1 consirlcrcornbiningrhinopllstl rvith ¡¡l,iircill ¡rroccrltrcsc\ccft fi..
lilr (rhis conrbin.rtionnrlkcs lil.r potcnri.rllvlong (lpcf.¡rivcti¡nc).

SNIERGISTIC PROCEDUR.ES:
THE FIVE COMPLEMENTARY PROCEDURES
Philosophy
'l
hc "llig Four'"tr'.rLiitio¡rirl
fici.rl¡csthc¡icploccdr,¡rcsficc lifi, brorvIih. blcph
¡r()Plirsty, irrd s(Úlcti¡lcs lhiD<4rl¡stv ilÍe the Drililrstir\'s()l_filciil ircsthctic
sulgclv.Holclcr, cvcrrtogcthcl thcr d() l()t bcqin t() atitücssitll thc chen¡lcs
ol'rhc lging firccsshol'n in Figs.l{) ,t ¡r)Lll0 5. FLrllvtrrr thirclsofthesc si!,ns
ol:rgÁg (lab td ir rtd) ctntxtt bc trc¡tccl bv thcsc lirul tr¡ditioral pr()cc
rlrrrcs.Bcc,ruscoLrrP¡ticntsoipcct lhc vcrv bcst,¡uos1n¡tur¡l rcsultspossilrlc
tiolr rrs,rveirsircsthctic plistic surgconsrrrrrstclerclopthe trxrls,skills,.rnLl jrrcla
nrcnt to dcliler "thc r'cstofthc ¡reckirec."
 The SvncrsyofMultimod¿l F¡cialRciuroation: Púftins hAllTosctfur 351

Clcarl¡ the besttoday is oftcn far better than our bcst of20 yearsago, If we
are to maintainour leadershiprole in acsthcticplasticsurger¡ we trrust bc
open to new cotceptsand new techniqucs,but not necessarily readyto jufirp
into everynew idea.As the old adagesays,"Be not the first to takeup thc nc%
or the last to leavethe old behind," We need¡rot all be pioneers.Pioncering
comcsat a price-new and unexpectedrisksfor our patients(suchasthe pro-
found hypopigmentationof aggressivclaserresurfacing,which did not bc-
come apparentto me (T.L.R. III) until f2 montis afte¡ I had becomcim-
presscdby the ¡atherremarkableimprovcmcntin skin wrinklesI could obtai¡r
with the laser).We do not all needto bc pionccn, but we do needto look crit-
icallyat eachnew conceptand seckthe opinionsof thosewe trust who have
morc cxperiencein thc particularare¡.

Furthermore,it is wise to remcmbcrthat vi¡tually every new techniqucgocs

through threephascs:
L The zeakt phase:The pionecrsardcltly promote a new tcchniqr¡cf'o¡'il
wide varietyof patients,
2, The leactiontryphav The broaderapplicationby newly taught discr-
ples b¡ings complicationsand long-tcrm problemsto light, anclthosc
who held offsa¡ "I told you so."
'fhc
3. n a.t,artpb6te:The appropriateapplicationand limits of thc tech-
nique are understood.

We now havc in our armarncntariummany techniquesthat havc bccn intro-

ducedin thc past I0 or more yearsald arc in this maturcphasc.Thescprocc-
durcshavcmucl'rto offcr thc appropriatepaticnt,often at lcssúsk th¡¡r thc tr¡-
ditiolal ones,yet somchavenot beenincorporatediuto our practiceor hrvc
bcer irco¡poratedody minimally,

Perhapsone of the gleatestenemiesof obtainingthe bestfor our patientsis

our naturalinstinctto find one rnethod(fbr examplc,for facelift or eyelidrc"
juvenation)and stick with it. This givesLrsa comfort zone and is commcnd"
ablc becauseit tendsto give predictableresults.But onc needsto look no ñlr-
ther than rhinoplastyto seethat this static,singular,one-size-fits-all
approach
will oftcn giveonly mediocreresults.

In the restofthis chapterwe presentfivecomplcmentarytechniquestltar mccr

drcsccriteriaand áre in the maturc phascof their applicaúon.An attempt is
madeto showthat thei¡ combinationwith the traditionalprocedurcscanyicld
an outcomethat is greaterthan rhe sum ofits parts.Thesesynergisticprocc-
du¡escanoften havea far greatereffecton the resuhrhanthe combinedcffi:ct
of the traditionalones.
Conbined Approaches
and Synergisdc
Procedurcs

Complementary Procedure I: Microfat Grafting

Tecbnique
Our techniquelbr mic¡ofat graftingis similarto that of Colenan; it empha,
sizesmcticulousharvestiflg,preparation,and ca¡eñlldrop by drop graftingto
ensurethe g¡eatestsurvivaland predictabilityofoutconcs.

Ma.rbing tbe Petient

FrG.l0 13

The patientis placedin a sittingposition (beforcanysedation)with thc surgi-

cal spotlight dirccdy overhead.Talgential light and its resultingshadowscl-
hanceone's ability to perceivethc most subtlenuancesof facialtopography.
Even in this srnallphotograph,the tear trough, malar facialfold, ¡asolabial
folds,mirrionettelincs,a¡rdlateralchir ¡olcnes can Dcsccr.
 ¡ l i ( S r r ) r r g \ , i ¡ l r ' . i , { 1 . , 1f r . L . , l r . r L , \ . ' . , i r ! r| ! L r i n s l i \ l L , , s . i l i ( ,

Sugical Sctup and Insh'tuttcuts

t : l ( i .t 0 l 1

SrfL4rktr m Íol¡t grafl n.l

( ) r r¡ l l ( ) l { ) r r rl ) l r ( ) l ( ) \ . r r(ri(il. l q r . l r ) r s , . 4 /¡i¡! r¡ ¡l ¡ r y ' ¡ ¡ .uus' ,e: tt1o s i q r r i l i. r r r . r l c l. ir, r

g,f.rll irr!t./i // ii )f li¡osLret ior. .rrti l/¿, l , rutlir cs .rr .rlc,rlirr'Lrscrrcsrrllirirg

l l ¡ e l i t r i r r o r ' , r ' c . r( L r s t r . r rl l r e . l i ) ( l ( ) n r c( n) f i r r e l l l r i q j r sl i t c . r s co l . r ¡ ¡ c s ,
. r r ( l l h c l r c r ( i¡ f c l ) r c l t . l r c¡(nl ( i ( l f . r l ) c si l i r r ¡ r r I t . r r r c o rlr. si LI ri o
. c . r i r1r \cr I r e . r i n c I
0 . 5 1 1r r, ' i l l rc l ) i r r c l ) h f r ri cs i n j r . l e ( ii r r t ot l r c t l o r r o r ' s i trc¡ r I ¡ r ' ¡ ¡ n r r ¡l rr ee n r o s r . r s i i .
( i e n c r ' ¡.lr r e s r h c siis. rL r s c lci lr r n r . r j oil. r s e o s r r n u l t i ¡ l tf c . i l ) r ( r rsl i r r \ il { r r . r.lr r r ( \
t l r c s i .l r i t l r s e c i . r t i oen¡ ¡ L r lLcri eL r s t ttl. ¡ r r . t l ltvc l l .

l r t( i . I 0 l i

)D>,,.al \ =...__,u':-- -2

H ¡ r v c s l ¡ { t1 e cr r ! ! c
'lhc
1 . 1i 1s l r . r f \ e s t cnr l¡ . u l r r . t lrhr i t h l l 0 a a r u i n g c r n r l r r n h 2 t o . 3 c c ¡ r l v . r e
u u r r . L ¡ c c ¡ u shci g h r . r c r r u m c . r n . l i s l r r ¡rth c t i r tc c l l s .
(l(!,,l)i.d,\r,rr)rd,rs t r . L lS \ n . i g ¡ ¡ i . l ¡ o . c d u i $

FIG. l0 ló Size ot Fat

Inside Diameler Tip Slyle Hole Diamele. Panic¡e
Beckerrasp I mm

' L a r g e ssl z e c o m p a l b ew [ h L u e l L o kd e v i c e

Hlrvcsling c.rnnLrLrs ¡rcslrorr'rr¡Lrovc.Ihc rrirLllc onc l¡lrclcr]"fiicc" hrlrcsts

l)¡rli.lcs 2 nlnt ir¡ Wc usc ¡hc cfficicnt kccl tip ¡:()nt()rrr
tli.rlttctcr. c¡nnLrli1.
\'lrich l).rr\cstsvcrv firrc¡irrticlcs.

!t(;. lo-t7

2 mmpances
L ú m pn e s so r e y eú ¡ l l e r g r a l l ¡ g w l h s l a n d a r d

If tit hl¡vcsrcd wirh rhc usril 2.7 mnr c;rnrrrrlir (2 nrnr cliirnrctcll).trliclc)is
ellficd in rhc pcriorbi¡rlilrcr,whcrc lhc skin is onlr'0.2 to 0.5 ¡rnr lhicl(ncss,tltc
lrrtNill srrrvivcvcrv rrcll, ¡rrcl¡licr i¡ll cdcnr¡ is resol!cd in rbout l2 nrtrnths,
rhc lLrnrpincss ofthc firt ¡¡lobulcsrvill bc clc;ul¡'r'isiLrlc thrrugh rhc sliin (or'-
'fhis
rr,¡'r). is vcrv fiLrs¡r-.1ting
1()rhc piticnl ;rnclsrrlgconirncllccluircsir ncrr i,,
.ision (s()nrctimcsnrrrltiplcincisions)(¡cr c.ich ql()bulc to tctlioLrsl¡scLrl¡rt
d¡¡vn c¡ch bul¡c. \\'c scrrchcdli)r ¡ l)ctlcr solu¡ir¡rlncl lirunclthc c¡rrrrul¡dc
signcclbl l:3ccl<cr (<ccFiq. l0 la);WcllsJohrrson(ir., l rrcsorr, AZl. rvhichl,.,.
nrrrlti¡rlcholesslr¡r'pcrred irnd ¡ugui¡te(l likc ¡ chcescgl-xtcr.lhis ticsi¡¡npro
duccs;rp:rrticlcebout 0.2 nrnr', (nlv xboul 5% ol rhe v()lLrnrc ol'Lhc sr¡r¡d¡r'd
c¡nnull f 4 t() ll mmr).
 Thc Sf.ers oi Muhinr¡l¡l Fici.rllr.c¡!^e¡dtnD:Putting ¡t Al1 li)gcrhr. 355

FIG. lO-la

M Rrc

'Ib
fl l; ilil1
grall¡g cár¡u as
Tfepsalfne-part¡cle

glirft thcsc linc ¡rrrticlcs,\'c usc ¡ blttnt 19 girugc cannulaclcsigncdbt

'l
rcpsirt(No. l'LAl (l)T3; l'ouret Mccli!-ill,(llich¡ Ftirncc).Wc hirvcncvcrsccn
ir¡r hl¡rpincss sincc rve chirrrgcdt<)tllcsc spcciil harvcstiug lrncl grifting c¡tl
Dulis. Howcvcr, onc shorrklrrrt ()\,clcorrcct:¡ \'cry high ¡trccrrtirgcofthcsc
litrc prtrticlcsrvill survivcin thc cyclirl,so dtc a[¡rgc(¡1
sh()ulciLrcconscrv¡rivc.

F I G .t 0 - r 9

cánn!tas(Coteman)
Grartins

To grLrftthc rcst ofthc firce(other thir¡tthc pcfiorbi¡.rlarci), Coicnr¡n'src€iu-

l¡r c¡nttr¡lasatc usccl.

F&t Prepttrtttion
The firt is ccntrifirgccl stcrilcly ¡t 2000 rpm f¡)f 2 ¡rirlutes. The oil is cicc:rntccl,
lnd thc ac¡uc<xrs hvcl is clririnecl()f't thc botto¡r.'l'hc ilr is then lo¡clccl
throur¡ha closeclsystcnr,rvithout $rtshing,into I cc s\rir!!cs.
356 (lrnnbin..l.lttkDchcs.¡riS\nLrciri.l',o...]ure\

Microfot Grafting as a Perwñncnt Bi.ocotnpatibleFiller

'l
he sinplcst rntl cirrlicsripplicirrion f'ol itutologous fat glirfiing $ rs the fiLling
ofclcfi:cts ficill rnci clscuhcrc.This puts rhc lc¡sr dcnan(l ()n thc grlficd 1ar,
bccauscit docs¡ot h¡r'c to maintiril ir shipc (asrcquircd firr eLrgnrcntirtior-r of
tlrc chccksor chin); it just rrecdsto nlirintirinirs \rtunc. Thcrc is o¡tc riifficult
irspectot th¡s ¡pplic¡tion, hoNercr':Oficn trlt¡te|er c¡.e¡tcdtl¡c tlclLcl or ue
pressiollincludcs significantphlsic:rl (r- infl¿¡nmato| tretrnt.r,rcs!lting ro
sc¡rdn!i ¡n(l r.icclc:rsccl
bloocl srrpph,.

fl(1. ¡0.20

AeslhetlcProblems SurgicalPlan
Mullipledeep laclaldopressionsfom acñe Microlalgralinglo acnedepressio¡s
scaf,nq. madeworse by: MACStifr
l¡ gene.al,no láserresuna.ngon cheeksror
ñ€ñ (hypopigmenral on)

'lllis
43 vc¡r'-oldrtrillt hid sevcrccystic¡ct)c ils d tecllirgcrlltcl N'¡s lcfi \\itlt
Drult\rlcclcc¡r.irrcuLrlerdcprcssiorrs o¡ his ticc. Thcsc lrccirnlcc\,cn¡ttorcno-
ticcirL)lc ¡s llc lgctl .rnr-lhis lici¡l skin lrcc:rnrc looser.With il clc.rrul]dcrstirncl-
irlg ofthc lirlit¡li(),rs. he u¡'rclcrrvcnt nticrr¡fittgr¡fii¡g l() lhcsc irreirs,irlorr:l
Nith.r trlA(lS lili. ln rlreseciscs,tlicr prcliminrrr.sr¡lii g, ir is |irrrr¡llt ¡l
\v¡\'sncccss¡rvr() rclcirse ¡rrr ch()rds(f s..lf tissr¡ethit billd fllc skin to the Lut
rlcrlvilg tissuc. lhis is rlcne sirh ¡hc \'-disscctor(picklc tirrli) sltorul on thc
l e t t i n F i g . l 0 l c ) F i n . r l l l . , r l l v e r o f f ¡ r i hs i d i n r h i s t u n ¡ c lt ( ) p r c v c n r t h er e i r c l
herc¡ceofthc sl¡.into its becl.
 ll. \'-(r!\ r\l rh ,,r,r l.(r'l '{.|,|,a,',{ |1 ia:Ir \ll ll,u |,( 357

¡lG. t0.20, codt'.l

'l
hc rcsultis shrlln .LtI rc¡r. l hc lr()(c(lurc nl¡tlc ¡ r.lr¡nr.rtic
dill.rlcnccin llrs
sclflcstccnr,¡nr1 hc l¡s c\tr.l(niinxrilv.ll)l)rcci.¡ti\cof oLrl cllirrts. Such.lcc¡r
.lr)(lsc¡rrc(ldclt'ctsr¡licDfcquifc.r scc()n(lslilgc.l)ul lh¡l w.rsrr()tncccss¡r'\'fi)r
t l l i sl ) ¡ t i c n t .

for Augmenting
Stru.ctutal Mict ofht Grafti.n¿1
SpcciJicFacial Arcas
Ruilding fircialstrr.rctru'c. ()nc ol thc rnrrzing things th.rt(irlcnrrrn¡rrovctlir
tlrlt fit gr.rfiingcorrl.lbc Lrsc.lnot onh rs ¡ lille¡. but ¡lso.rs.r tissLrc ti)r.ltl.-
rlrcnti¡rg.rtrd ¡c!Lr¡ll]'chinqirr!¡ lici¡l stlLrcturcs.IIc eitllctl this tcchrricluc
t t rr rt t trru I .lirt rtrtrli i u1¡-

Quantity of fit nccded. l-hcreis r sig,riiicrnt,sonrc\ hitt prcdict.rblcrcsorp

tion (}f thc fit. rr'hichr¡rics fir¡rr ¡r'crtto ilr-c.1.llrr l)cr.clrl l.c¡irsorircrlis
r'orrghlyirr pr(rp()l1i(n1()thc lur()unt ()f nr()\'c¡ricrrt
in tlrc irrc.r,r'ith grc.rtcst
fcirbs(nl)fir)rirr rhe Iips,¡ncl lc,rstin rhc n)¡ll iue¡. An ir¡pr()\irrl¡tccstin)¡tc
'l
oi thc ¡mornt ol fit ¡rccrleriis shorv¡ in rtl)lcl 0-1 .

Special corrsiderations fbr grafting each ll¡ci¡l ¡rc¡

F()R!:rrEAD ANI)FR()WNLINLS.F()rchc¡cl¡¡¡.1ti()!v¡ lioesirrc dcnsclvtclhcrcrl
t() thc !¡r)dcrl\.in!i nrrrsclc. \\¡c gr.rli innrcdi¡rtclvurrdcrthc li¡cs to disrerrd¡rld
l i l l t h c n : r s n r u c hi r sp o s s i b l c(.< , t t t l o . " : L r s cr c ¡ v k x r ' y r r c s s r t r e . uot rnl h i t
lrlunt c.rnnulalol grlf'ting hcrc. fhc vcirtsir'r¡unr.l thc t¡ bit h¡vc no vllvcs.¡nrl

I
358 Coñb¡ncd Appr@ches.nd syncrsistic P¡Gedurcs

Tsblo 10-1 Volumc ofFat G¡aftedand Degrceof Resorption

for EachFacialArea
Deg¡e of
lYpiel VolM. of F.t c¡aftins
Gl¡bclle¡ ftrrows Moderateif coffugator l-2 c.

High ¡f corrugator not

Uppcr lid hollorv ModcnteAigh 2-4 cclside

Tear trough/r¡¡lár facial l-2 cc/sid.

Mal¡l I0-I5 cclsidc

'
Su¡kcnmidcheek Modúatc/high ó-ró cc^id€
Nasolabi¡llbld Hish 5-8 cclside
Lips Hich Uppcr4-ó cc; lower8-12 cc
High l5-25 cclsidc
Ch¡n High l2-2O.(
Hish 3-4 cc/sidc
Templcs(intr¡muscular) Moder¡t€ 6-lt cc/sidc
Etrt¡rcvcrt¡c¡lhcightof High L2-2O..
uppcrlip fo. intcr¡or
ml llaryhypopl¡si¡

embolizationto the letina is possible.)A V-shapcddisscctoris thcn usedto

rcleasct¡e band of attachmentto the underlyi[g musclc,and finally a small
amountoffat is laid in this tunncl to minimizc reattachmentofthc skin crcasc
to thc musclc.NorE: Unlcssa brow lift with deactivatio¡¡of the co ugator
m¡¡sclcis also perfolmed, there is a much grcatc¡ chancefor recurrenceof
thesclines.

INTRABRoVUPPER LIo. Grafting the infrabrow/upper lid was the insight aDd
geniusnot only of Colemaf¡,but alsooflámbros. We had beenrcmovingfrt
ftom the uppcr lid firr decades,so adding ooluweby graftirg this arcawas a
conceptthat took a long time for acceptance, But Lambros'sserialphoto-
graphsofthe agingpc¡iorbitalareaa¡econvincingand shouldbe studied.The
readershouldreviewFigs. I0-l and l0-ó and refe¡to the earlicrdiscussionof
the sunkenupperüd. BcforegraÍiing,one shouldrcviewin detailthe anatomy
ofthe upperorbit asit is carefullydescribedand illustratedby Zide and Jelks.
 The Syne¡syof Multinrodal FáciárRejuvenationi Putting Ir All Tosethe¡

FrG. 10-21

Microfat grafting to the inf¡ab¡ow region is performedüth the l9-gauge

Trepsatcannula.The incisionis tiny and placedfor bestaccess to the superior
orbital ¡im. Note the angleof dre cannulashownin two planesin Fig. l0-21,
,4. The surgeonmust exercisecautionto avoidinjury to the globewhen feath-
ering the graft down iuto the upper lid. In Fig. 10-21, B, grafting hasbcen
completedon the patient'sright lid and the resultis a smooth transitionfrom
the brow to the upper lid in this 37"year-oldpatient.

Any graftingin this areamust be donewith a blunt-tip cannulaand under low

pressure(becausethe periorbitalveinshaveno valves,embolizationis a possi
bility), For grafting the areaswith extremelytiin skin (the eyelidsand tear
trough), we useonly a speciall9-gauge blunt-tip cannulawith a sidehole de"
velopedby FrankTrepsat(seeFig. 10-18). In dre periorbitalarea,we useonly
dre flne particulatefat harvestedwith the Beckercannula(seeFiE, 10-16, top).
Literally only about 0,0I cc offat is depositedper pass,and that is done ody
d:ni,r'gtíe withd,rawalphaseofeach pass.All oftheseprecautionsaretakento
minimizenot only the risk ofembolization,but alsoto dccrease the chanceof
a largedepositsuddedybeing injectedunder the thin eyelidskiu whereit may
be visibleasa lump. The fat shouldbe usedto build downthe utperiororbital
rim, zolto inject blindly into the recessoverthe globe.The surgeonshouldbe
conservative in the amount g¡afted(start with I to 2 cc per side)until long-
term experiencehasbeengained.It is much easie¡to add more later than to
try to removean excessamount.The percentsurvivalhe¡eis variable,and the
surgeonmaybe surprised if too muchremains.
360 CombinedApproaches and Syn.rgisric P¡ocedúres

rrc. to-22

Tlis ó3-year-oldwoman hassunkenupper lids and infrabrow area.Immeor-

atelyaftermicrofatgraftingto this area,with about a threefoldovercofiectior,
the amou[t ofloose skirlthat wasco[cealedin the orbit is evident,asdemon-
st¡atedwidr forcepsin Fig. 10-22, C. Skin resurfacingwith the Sciton laser
(two passesat 80 micronsofablation,50 micronsofcoagulation,and 50%over-
lap) servedto heat-shrink(or tighteo) and smooth t}reperiorbitalskin;only a
minimal excisionofupper lid skinwasnecessary. The earlyresult at 20 daysis
shownir Fig. 10-22, D; comparedlis resultwith drc preoperative view in Fig.
lo-22, A.
 'lhc
S\ncrg! ofll!lLrnr¡l¡l f¡.r¡ ltelrtr.¡i¡ntr: hri¡i.g ltAl logc¡h.r 3ór

MICROFATGRA¡TINGTo THE TEMPLES.A ve¡v comnroú cor¡poüent of tl)e

liaulrting,pattcrn of agill¡r,is thc rppcrrincc of¡ sunkcll tcmple arca (thc iuc¡
supcrficilL to thc tcnrporJis mlsclc, bct\\.ccn thc zyllorr¿tic ilrch ¡nd thc tcrrr
¡rord crcstofthc skull).This rtlophJ'ofthc tcmplc arc¡ crn bc sccn in c()nl
prring figs. l0-1, ,4, ¡ntl l0'1, B. Thc tc¡rporll crcstlinc is clcrrl,r'visiblcin
I,ig. l0 l,,tl, btrt is r¡relt,scenirrvoungu'on¡enofnornr¡l \\'cighf.

(irrrcctin¡¡ thc hollorv tcmplc is bcst tlonc bl microfit grei_tingiuto thc sutr
st¡ncc of thc tcmpor:rlisnrusclc(rathcr th¡n in thc sut¡cutir¡rcous phnc) for'
thrcc rcls()ns:
I Thc subcut¡ncor.rs phnc is oticn vcry thin in thcsc pirticnts,¡nrl cotrld
not holclcl]ough firt kr cr¡'r-cctthc dcírct.
2. Thc dcc¡rsurficc ()fthc sul-ralr¡i1r1c()rrs ¡rlirrrc(iiborc ¡nd Lrcklv thc st¡
fcrficiiLlrcnrl(r'¡l fhscil) is r krosciuc<¡liuzonc. F'irtilrjcctc(lsubcuti
nc()uslyNill c¡silvdisscctint() this kxrscplanc,r'csLrlti¡g, in ir ¡rrrrrlvvas
culilrizcdplncrl(c of firt,t,hich l ill likclr,Lrcrc¡bsorbc(1.
3. l hc subcuhncoustcnrl)()rrl¡rllnc confrins thc supcrlicirltcnrporrl iu
tcfy ind scvcf¡l lirrgcvcins; (¡si¡rgthis l)l¡nc wot¡ld thr¡s rlso incrc¡sc
l l t c r i \ k , ' t . r q r ] l i i , l r tct c . h r l t t , , , i r .

It is bcsf 1o nrrkc l snrdllincisiondorv¡ l() thc (iccp tcru¡roritltitsciir.!ig. 1,,

23,,4, shou,sthc trscol thc rcnr¡or-rlincisionol thc cnriotrlo* lili fit:rcccss.
A nruchsnllllcr incisionc¡n bc usctlif¡n cntftrirrol'lili is n()t l)ci¡q (i()nc. lhc
dccP fcnrp(¡'¿lfirsciiris <4rcnct1 ['ith i N(). I I b]irclc,¡rnclthc (blcnr¡n Ill-7
cilrrul¡ is Lrscd.In fig. l0 23, l, Lhc righl tcnlplc h¡s bccn gr¡ficcl irrci thc
lcii is sLillholklr'. llcciusc fhis gfilliing is cortplctclvintlirrrrLrsculitt.
uc rvoulel
il¡ticip¡tc ¡ Inuch highcr sr¡rvir'¡lr'¡tc i!r(l w()t¡lclrccr¡rrnrcnclonlI ovcrcr¡'
rcding t))'25% r() 30%.

FIG. t0 23
362 ( l ( , n b i n r d A f p r ) r e h ( \ , rr l s ! ¡ . f g i s t i . l , r r ) . . d L r r f l

TEAR ÍROUCH ANI) MAIAR IACIAI. (iROOYF:.L)nh thc tinc p:uticulite fit
shoLrltlbc usctl.()nc musr remcnl¡cr'th¡r the o¡tricul.rris r)culin)uscleis hcrc,
Jrld therc Inrr t)c rn unusu¡ll| high sut|i|i¡l ratc.so .r D()\icc shouldstirrt\ ith
0.5 cc until ruorc cxpcricrceis grrincrl.\\t rirrch usc Il]()rcth.rn I cc; u.c tctt
lhc paticrlt th¡t \r'c woLrlclrilthcr c()nic b¡cli I sccond tinrc thirn oversh(x)t.
'lhc
f'rt is gr.rftcclin irll l¡yc|s firrur thc Lrt¡rcu| to thc (l(in, lrrrtr¡nlv 0.01 cc
pcr |.rss. lhc g,r.lfiingis fi;rthercrluP lionr thc tcirÍ o'otrqhto wirhin rrL)()r¡¡
5 nrrn ofthc lirl nrrlgin. This rnctlrrxlnt.lkcsit p()ssiblcto con4rlcrclt-obscrrr'c
thc lirl chcckjuncrion,prolitling.r nrtrchnt(ne\1)uthfulcrcli(l irppc.rr.rtr.c (scc
liis. l0 6). A lrr'po¡rhsticinfcrir¡-ortrit.rlrir)tc¡n irls()trc [rLriltLrpro,]r.rrkc(tt\.
i n p f { ^ c t h c l p ¡ c u r r n c co l - t h i si r l c ¡ ( s c cl r i g s .l 0 4 . 3 . r n r l 0 ' 5 . 3 ) .

MAI,AI(^REA.A rr'cllpr'<4rortioncrl chccli hrrrc c¡n idd sfu niú!t,bc¡ulv fo ¡

rrr¡u¡rr's fircc (|ig. l0 2,1)rnrl ¡ftr'¡crivclcss¡r ir m.rn'slicc (Fig. l0-25 ). l-or
lhir' rcls()n,ir is rvorth studvingtllc lhrcc dirncnsi()¡txl ¡n¡¡rnrv ol rr l)c¡r¡tifill
chcck. It is not sinr¡h thc nrellr cnrincrrcc;irr its firllcstcrplcssion.rhc fi'nt¡lc
chcck c\tcnds irr r¡rc continrrorrs c¡¡r'c ¡ll thc rvlr,dortn to rlithin 1.5 c¡r rf'
thc c()fncr ()fthc nr()uth.Its ¡ris thcrr riscs¿1¡/14¡¡¡l¡'rrP
to tllc sirlcburn-Its cr-
tcnsi()n (^'cr lhc /yg()nril¡ic¡rclr is Drf lroiizontll, is $'c n1igh1sul)p()sr;
f.rrlrcr,it t(x) riscsolt/it¡ttrhttp ,trrl t it rrr{)vcs
p()stcri()fly.lhcnr¡¡einsofthc
chcck slrorlcl gcncr.lllvbc s()ti tin ¡ \\()o1.rn(trnlcssa strrle, irthlcticl{x)k i\
dcsircli). F()r rl rr¡in, thc clrcck bt¡nc slrr¡lltl hirrc ¡ sintilrf ()ricnt¡ri{nr,[)!¡t
h.tlc ¡rruc chisclcrlkxrking r¡lrgi¡s 1l;ig. l0 25. .ll).rnd n()t l)c.rs firll ()f c\
tcncl ¡s t.rr inlirior'h its¡ \'rrll)¡n's.-l hcscrict.rilsJrc n()t itltuitirc iltr(lrcqtrirc
s()nrcst!¡(i\¡,

'li¡
hrrlvcstfit to lrc grLrlLcLl into rhc nr¡l.rl rrlcir;rnclt|rrn. *hcr'c ¡hc sl<ini"
lllickcf rhirr rltc Pcliorbir.rl¡rcl, lhc rclrLtl¡rh¡r'vcstinl.l clnnul¡s of (lolcntrrn
(n'thc 2.7 rnrn Il) rrith thc kccl sh.rpctlrip shorvnin thc n)i(l(llc()f Fis. l0 ló
¡r'c trsctl.Tlris hrtrrcstsptrticlcsi¡b()ur2 ntrl in cli.rnrctcr, l hich is itlc¡l tiu tirc
rcst ofrhc thick sliinncrl¡re¡ ()fthc l¡rcc.F¡t is qr¡ficrl onlv rlrrringthc rvith.
ph.rscofcrelt Iilss (t() mininrizclhc risk of crulroliz¡tirrn).()nll I cc s,
tlr.rrr'.rl
ringcs lrc Lrscrlt() nririrnizc thc injccliorrp|cssLl|cnccrlcrl. lhis ¡rr-eclution
¡lso ¡nininizcsthc ris|r.of cmboliz¡¡ionirltl rhc ¡rossibilin,thrr.r [rlock.rgcgir
irtg lll suclclcnlrc()ul(lfcsult in e lllgc bolus of fit bcing dcpositcclin onc
¡rcrr.No nrore rhir¡ 0.I cc is clc¡rositcd ¡krnq rhc 2 to -l cnr p:rrhoftfrc cennu,
l¡rr¡r c¡ch p.rss._l'his tcchnitluccnsurcsthilr lhc f¡t \ill lrc rlcpositcdi¡r ritN
rlrr4rlcts,ir¡d thirt citchclustcr()flil ccllsrvill lrc surloun¡.lcri l¡r' thc trlootl sulr
ply ol-nor'mll tissuc. lir injcct l clc¡rosit$cn ¡s sm¡ll ¡s I cc \\'() lcl crc:rlc¡
l¡kc of ¡ronvieLrlc tiss!¡cl()nl]'tllc pcriphcr'yin cont;rctrvifh strlr'or.rnciing tissuc
rvill survivc; qrcirtcr thrr¡ 95% *ill bc rcrrbsorl¡cr.1.
lh.\\¡.r!\,n \ l L , l ( r r r ¡ r 1¡..rrL. i r L t . t \, . , r . r 1 , ¡ rl :) L L frt! l r , \ l l l 1 i { . r ¡ r r 363

FIG. l0 l.t
B

I0 25
364 Conbincd Approlchcsan.tSyncgisii. Pro.cdurcs

FrG. 10-26

Augmentrtion of thc malararcais frcqucntlydonc ¿t thc sametimc as¿ ficc

lifi. Grafiing is dwayscourplctcdbcforethc ficc lift is bcgr"rn.It is ratural to
wordc¡ irow the ñt could rcmainin positiononcc thc ticc-lift flapis clcvatcd,
, r r r dl r o wi t c r ¡ u l ds u r v i v (cF i g .l 0 - 2 ó ) .

ln Fig. I0-2ó, microfatgraftingto the nalar areais completed,includingabout

30%to 50%ovcrco¡rcctior,bcforcthc facclift is bcgur. For graftingthc maiar
arca,two incisiols, cach2 mm, arc uscd,onc ir thc sidcburnand onc on tirc
nala¡ cnincncc. Thc chccklooksappropriatclycxaggcratcdat this point.
 The SynergyofMdtinodal Facial Rcjuvenation: Putring It AI Togethd

The samepatient is shown aÍie¡ the dissection for a MACS face-lift has been
completed.By comparingFig. l0-2ó, B, with Fig. I0-2ó, C, wherea blue tape
hasbeenplaced around the grafted zygomatic a¡ch and mala¡ a¡ea,one can see
that the mound c¡eatedby the grafting remainsundistu¡bed.

The ¡easonfor its stabiüty(and its survival)canbe discernedfrom Fig. 10-26,

C Each cluste¡ of fat cells is firmly embedded in and immobilized by the fr-
brofatry tissueover the zygomatic arch and malar eminence.The fat cannot be
rubbed awaymechanicall¡ nor wi.ll it be displacedby pressureon the mound.
An analogoussituation would be to place multiple tiny piecesof rissuepaper
into gelatin before it setsup, then after gelling occurs, tying to squeezeout
or extract tlle p¡ecesoftissue. It cannot be dislodged, no matter how hard one
tries.

We prefe¡ to augment the malar arearathe¡ than elevatetie mala¡ fat now re-
siding in the midcheek area.The rcasonsfor this follow:
1. Once mastered,microfat grafting is simpler and quicker (about 3 to 5
minutestotal for both sides),
2. With grafting, the surgeon has complete cont¡ol over the degree of
augmentation and thc contour desired,including where the high point
shor¡ld bc and whethcr to continue the augmentation along the zygo-
matic arch.This degreeofcompletechoiccand control over contour is
not possible with cheek implants, which is a longcr proccdure with
problcms that include displacementand visibüty ofthe margins.
3. Most tcchniquesalso clcvatethe skin into ttle lower eyelids,causing
bunching and rcquiring sKn cxcisionunder the eyes;grafting avoids
this problem.
4. Some techniques, such as the tn r¡bkphq,llplast! chtehm c rry a sig-
nificant ¡isk of ectropion or otüer distortion of the eyelid margin when
the lift rclaxesand the soft tissuebeginsto descend.
5. The meticulouslyrepositionedfat that is sutured in place in Little's
technique, creating beautiñ ly sculpted cheeks,will probably remain
longer than tissue that is simply lifted, but the trade-off is a few extrá
hours of surgicaltime (comparedwith 3 to 5 minutes for microfat
grafting to the cheeks).Surgeonscan aspireto createthe beautifirl o¿aa
cbl're ú1afIiffJe frrst brousht to our attentiol,
a o a b l e d A p p r o r . \ r . , n d s , e r g F, . l t o c e d , ' e .

AUGMENTAIToN oF THE cHrN BYMTCRoFAT GRAFITNG.Plastic surgeonshave

long beenawareofthe itcrcaseit youdrfuhessand att¡activenessthat can be
achicvcdby addinga chin augmentationto a facelift when a patielrthassome
dcgrceofmicrogenia.Similarl¡ in somcrhinoplastypatients,a weakchin makes
thc flosclook cvcnlargcr.

FtG. to-27

Both of thcsc cf'fi:ctsarc demo¡rstratcdby comparingthe prcopcrativcand

postopcrativcvicwsofthis paticnt.Thc rcstorationofncar-idcalfacialpropor-
tions,in combination with the rhinoplasrya MACS-1ift, and miror liposuc-
tion of the jowls and neck,clearlyhavea damatic tlrr¿t'gisticef:1r-ct:shelooks
not only yoturgcr,but morc clcga¡rtarrdmorc attmctivc.Thc chin augmclta-
tion rot only rcstoresharmooywith thc n<>se,brtgivcsa longer,sleeker lookto
tb janline. Anvthing thrt intcrrupls thc smooth, crisp linc of thc jarv takcs
rwry fion this cf'ftct.:rsl'ill bc shorvnirr thc ¡ext two scctions.

AUGMENTATToN oF THB r-{rBRAr cHrN NoTcH. The triangular shadow (just

latc¡alto thc chir in Fig. 10-27,,4), which suggcstsnotchirg ofthc mandibu-
lar margin, is a common sign of aging. Although this notch is not a major
problem,it hasthreenegativeeft¡ctson attmctiveness: (l ) detráctionñom thc
crispness of the jawline,(2) tendencyto makethe chin look pointy and nar-
row, and (3) tendelcy to exaggerate the fullnessofthe jowl.
 T h c S \ n c r g v0 1 l l L L h n ¡ o d ¡ l l ¡ ü ¡ l l t ( l L \ c . ¡ f o ¡ : l \ , I ¡ L ¡ g I ¡ A I l ¡ ! . c ¡ h c r 367

FIG. t0-27. conCd

Aesthetic Problems SurgicalPlan

Deep nasolabialiolds,depressons
aro!nd moulh,a.d ¡olches ol
mand bularma.q n al aleralchin
E¡dobrow lft perorbila laser resulac-
ng. and ma ar augmenlation
Microrat9rarling(o lear tr0ugh
M¡c.olargraltingIo mandibularnolch al

Ch n algmenlalon by m crolal grail nq

M d i o w n g a n dc e t o c a la x l y L posuclionol lowland neck
MACS- il

'lhc
bcnclit of micf(fit gr'.rfiingis strbtlc,but visiLrlc{)¡r irll ric\\'s. lhc chirr
kxrhs lcsspointv, thcrc is no rcsitlLrrlhint of .r jorvl, lnd tlrc j.trvlincis lono,
snr(x)th,rnd clclrh,dcfinc(lfiom thc neck.Fig. l0 27, .l),sho$s fhc prficnl's
lirll surgicrl¡rlrn.

Or¡ this and Ltll substquL'ntüi!L:!..i11:,1trcprLJalttJtrrür¡ t0 hL:grn.fitd, rcrl i di

.fiͿr ar[ar t0 u dcin| lil ostrctirn,an d blach|Ltliu t r orc thL trl'ttr!_li1',]Jtr r$ltr'

-dt
3ó8 c , , m h i n r J A t t , , r c h r \ r r J S v f r , g { i ! 1 , ,r . L l u , t s

FIG. l0-27, cont'd

The crispness ofthe jarvlincin Fig. l0 27, ¡ (cre¡tec1 [r"vmicrofht graftirrg;

to
thc chin ¡nd l¡tcral chin notch) is furthc¡ clhurccd bl,liposuctiol ofthc jorrl
¡nd neck ancia MACS-lit''t.The 6n¡l three elementsofher firci:rlcnhirncernen¡
rverenralirrlugment¡tion, pedorbitnll¡rserresulficingto implove the wrinkles
¡round her eyes, ancl ln endobrow lili. These thfee procedures alone grve
complete rejuven¡tiolr ofthe periorbital lrea; no ble¡rharoplastyw¡s necess:lrf
 Th.S\..fu!,Jl IlLrIif¡tri]L lj.,fi.,l{cir\e .nl,n: núrin{ I¡ AIL l¡q.t1c. 369

FIG. 10.28

{LÉ
a
A € s l h e l i cP r o b l e m s SurgicstPtan
Droopng rarar¡ brows g¡vea "sad or

M.rolal a¡afl ng lo lear l¡ough nasolaba

Oeep nasoabrallolds.depressionsa@und lolds and depressonsaroundmoúth

Nolcheso{ mañdibularmaron ar ateral Mlcrofalgrafl¡g lo aldralchin nolches

Lp algmenlalo¡ by mrcrofalgrallrng
Minorhposucroñ ol low s
MACS,ifl
W n ¡ k e s o f e y e sa n d m o ú l h P e r o r b l a r a n dp e r o r a la s e r r e s ! l a c i n g

'l
hc thrcc nc¡¡.rrivc ctli'cts()f l he lirlcnl .lti norch lbss of .r srrrrxrrh, cris¡ j.rrr
lirrc,e tcrrtlcnct'firrtllc chin to kxrk pointv rnrl rrirrrotv,¡¡d thc cr¡qgcr¡tion
()l ¡hc j(r\\l) ciut bc sccn bil.rf!tlrllvin thc p:rricrrrin liis. I 0 28, ,4. ( irrr.ccrirrg
thcsccliclc¡sbv ntic¡()titr¡lrliir)g in thc.rrcirssl1()\rnjn rrccl i¡r Fiq. l02tj..ll,
is ¡n c¡st, tluick lr()cc(lurc llr¡l c¡u r-c\crscrhcsctltrcc Prrrt¡lcnls¡ntl is wcl
\'()fth irr(lL¡sirnin our ¡r¡t¡nlcnteriunt.'fhc lcst ofthc ¡l.rnocd ¡rrrrccrlurcs
¡fc listcdl)clo\\'.I'r Fig. l0 2lt. (-, shc is scen I vc¡r l¡osroPcr-¡¡ivch

'l
hc proccdLrrcs thirt hecl tlrc gr'crtcstcft'cct()lt rcjL¡\'cltilti()lt
in this l)aticnl
scrc ¡rrob.rblvrlot thc trircliri()n¡lproccrlurcs(ticc lili.rnd bros lili); r..rthcr,
lhc dr:rnr¡riceflects¡r'ountlhcr'ntouth rnd elcs ¡.csultcdli<:m nricrrfit erillr
irrg irnd lascr-r'csurfieing.
Ar Lrgc52, irficr.rhcclcrrhofher hLrsL¡¡nd 2 vcerse¡r.
licr, shc \rrs rc.rdvto Llct¡ ficsh s¡¡r't¡¡ lifl.

¡
370 .ornbrreJ qpp"{.1e. Jrd \\ riCi!ic I'rocedL-.,

AUGMBNTATIoN oF THE ANGLEot rHB tAw. When the angle of the jarv is
poorly defrnedor too oblique, augmentationof this area (gonioplasty)can
havea positiveeffecton facialatt¡activeness. A crisp,well definedangleofthe
jaw, sitlratedabout I to 1.5 inchesbelow thc ear lobe and forming about a
120-degreeatgle (Lindauer,personalcommunication,200T),is a featurccom-
mon to manyattractivewomen (seeFig. 10-24, B), and to most supcrmodels,
and thus is a pa¡t ofthe definitionoffacial beautyin both North Americaatrd
Eu¡ope.

FIG. 10-29

By contrast,this patienthasa jaw angle(thc gonialangle)that is more obtus",

creatilg a high mandibularplaneanglc.Insteadof nccting the asccndingra
mus at a little g¡earerthar¡a right alglc, the mandibularmarginriscsobliqL¡e
lv toward the earlobe.

This high mandibulirrplaneanglc is often associated with two other featurcs

that detractfrom the appcarance ofthe jawline:(l) a wcak chin (microgenla
or micrognathia),and (2) a true boly notch itr thc posteriorone rhird ofthe
margill of the mandible(the antegonialnotch). This patienr demonstrates
both ofthese fbatu¡cs.In addition,shehasthe previouslydescribcdnotch of
the mandibularmarginat the late¡alchin. Thr¡sshehasalmostall possiblefac
to¡s that candetractf'romthe appearance ofthe jarvline.(Thc only other con-
mon factor,rvhich this parientdoesnor have,is a thick submentalfatty de
posit. This f'eaturecall makethe jawlineindistinguishable f'rolrrthc neck.)
 'IhL
S\ner8\ ofül!ft1n!¡1rl Ir.irl ll(jLncn¡innr: h,u1¡q lr AllT1)qtrh(r 371

The re¡sot lirr thc frequerrtrssociation<)frrricrogcni¡$itlt irn ol)tuscanqlcol'

the jirrr and l lrigh nrlrrclibul.rr'pl.rnc irnglc is thtt thc ntorc r4rcn. otrruserrnglc
ofthc jalv causcsthc chin t() rotiltc d()\rtt\v¡rcl¡ncl postcrio¡lv. rcsultingiu lcss
l)rojccti(n ol'the chin (!hat is, ¡ticroqcni:ror micrognirthia).lt is int¡rortentt<r
kno\'th¡t this ¡ncchanisntc¡n lcsLrltitr scver¡lp()ssiblcdcntoficill problcnts.
llcc¡usethe nr¡ncliL¡lc is short lcl¡tivc t() thc nlexilh, elms II ¡r¡lc¡cclusir¡ris
.()nrron (rctr'ognirthic: lorvcrtccth too lir bchinclrhc uppcf tccth), ¡nd Inxy
reqtrife()rthodooticsirnclfrÍ orthounathicsr¡rgeryto c()rrcctrl¡c untlcrhirr¡r,
skclct¡ltleti¡r¡riO.Thc obtrrscjirrr'irnglccirnc¡Llscthc l)()stcriortcctlt to c()utc
in cr¡rtact bcfirre the ¡ntcr¡or tccth, rcsulting,in rpen lritc rlclirrnritr',r.hich
rviil recluircolrhrxlontics¡nd p()ssiblcofthoqnirthicsurl.¡cry t() c()rrccr-f,\ccs
sive lcrtic¡l nr¡xillirrvg,lo\\,th(vcrtic.rlnrirxillllv c\ccss)cun c¡(¡sclhc nt¡n
tiitrlc to rot¡tc tlosns¡rrl .rntl ¡rostcriorlv.rcsultinqin ¡ krrq licc svndlomc
lncl ¡ l,cirl<chin.

IJcc.rr¡sc of irll thcsc potcllliill ¡.lc¡rrotirci:rl

¡nont.rlicsrlrrrt nr¡v bc ¡ssoci¡tcd
Nith ir wc¡k (r-obtusc ¡¡tr¡lcol'thc j:rl irnrl high ntirnrlil,rrlrr¡hnc .rnglc,r/'
tlttrc is a¡n,ntrh¡tcltuiut, ottt sltotrltltortsi¡lt:rolttnititn ¡n ortboirntir/at.tlnll
itñtlJi. ro|st l lttlirt utltrtrltinl¡ colt.Lt:tio ol tl)$. !1.o[]h t¡ hi' ,¡irn'litt!tt.!t_ll
ittli trttd/orlillsuctilr. Il this sr¡flicr!Ncr'crlorrclilst, rnd thcll ll)c |irticnr ltt
cr \\'rnicd t() c()rrcctthc cl¡ss Il n)irl()cclltsi()D, rclDr¡.rlol ¡rr() ¡l.trill¡rI tccth
¡ld (n th(xl()ntics¡r obtlin dc¡titl irlignrtrcntnrichr bc rcclLri¡crl, rrltich ltriclrr
Ic¡tl to sonrc¡ntcrir¡' nl¡rill¡rl dcficic¡cv.

In fhis p¡ticn1 no siqnilic|rntofth{xl()¡)fic()f

()r!h(x:oithic(lcti)rnritv\'.rs prcscr)t,¡¡td lllc
rbrxr rvrrsailrfic(l()ut. (;rd,
|lrrn illLrstr'.rtcrl
rcPrcscnts.uci¡sl() bc gf¡ftcd, ¡¿11inrlic¡rcs
rrrcrsfrr L||relcl{olip()sucri()r1,t¡t',Iltl¡tlt ottt
1¡a¿'.r
¡tc irtc¡s firr l¡scr rcsurficirrq.lhe ¡/¿¡l,
47-rr,(le¡r troush ¡rrdf)f nrrl|rrticirrlgr'tx)\c)
is ¡ sLrLrscc¡ionofrhe hrgcr nr;rl.rr.tr-c.r thrt rc
r¡uircss¡rccific¡nd tlil|ircnt fechliquc t'i{)nr
thc !r.rl.1rrcqi()n.
372 . ' J \11 '..', L\',(.-rr. -.'1,

Her results,sholvn in Fig. l0 29, E and (i, 15 months ¡fier her surgerv,
clemonstr¡tethat a substantialaugmcntrtionofthe angleofthe jaN has bccrr
achievetl,along *ith a smooth, crisp mendibuler margin. I'he antcgonial llcl
latcralchin notchcsin thc miudible hrve beerrconrpletel),obscurcd. Thc alr
glc of thc jarv is no longer missing;it is norv a crisp ilnglc of ibout 125 dc
grccs,situatedllbout an ¡lch below thc cark)bc.

ñlost dramatic,howcvcr,is thc tremendorLs svnergvofsintültilncorrs¡Lrlirrrcrr

t.rtion ofthc cl-rinal]d thc an¡¡lcofthe j:ru'-'lhe rcsultrnt sn]oorl-rjcrisp,dis
tirlctivc jawlinc coll\'cysnot onlv ¿ttrrctivencss,[rut llso I senseof¡,outhfirl con
lidct'tcc or strcngth, rvhcrc¡s the comnron clescriptior'lofhcr prco¡rcrativc a¡r
pcrrrluceils hevinglr rvclk chin irntl u,cakjir$linc is soruchowsubconscioUsly
interpretedis indccisivc¡css ¿nLla hck ofrssertivcuess.

Hcr' finll ir¡Tpcrtlnccrvrtsirlso cnh:rncedby .r MA(IS-lift, ilong with uppcf

blc¡Thirroplirstv
with lilscr rcsurficing of thc ¡rcriorbitll .lrcirto dccfcascthc
rvri¡rklcsind thc Llarl<
circlcs;nrlllr lncl li¡r lugncntrtion; nricrofirtgr:rfringto
thc tc:rr trou!!h, nlsolirbi:rlfirlcls,ancl lal¡ionrcnt¡lsrrlcrrs;
lnd lipostrctiorrof
thc nrccli¡lchccks, jolvls,irntl nccl<.

'l
rvo strlgcsu,crc fccllrifcd,bcc¡Lrsc tirt glirfiing thc Lrnglcofthc jlrv cirnnotbc
cionc¡t thc sir¡rctimc irsd f¡cc lifi. Unlikc ¡hc nrllirr irrcl, lvhoscthick fit p¿d
c:rn bc grirficci ¡t thc sxDrcproccclurc ls i ficc lif't, thc illglc of thc jarv hrs an
cxtrcnrclythin sLrbclrtilncous lilycr thdt is clisruptcclby .r trrditionil firccIift;
enclthc MAOS-lilt pLrtst(x) rlruclltcnsion()Dthc mirssctcrnlusclcfirr sinrul¡¡
nc(\ls fit gfirf-tst() sur\,ivc.(lcrtiinl,vgctting rirl ofhcr cxccssr¡ppcrcJ'clici skill
rvls irn¡rortlrrt,btrt thc grcirtcstcfl'cctc()Dcsfi1)nrhcr nc$ hi¡¡h chcck L)oncs
irnclcrispjirrvlinc.
The Syne.sy ofMultimodál FacialRejuvenatioD:Purrins Ir All Togethei

¡IG. 10-29, co¡t'd

( ' { , L r i r ' .r \ . . r , . 1 , .'.1\ r',rnr l',,r.f.ra,

ANTEr(rOR ¡LAIIl,r,AI(y Hyl,()l,r,AsrA.lhis pirticlltof L)r. PatricliTonllir.ri(Fiq.

l0 .30)lcqllestedcorrccti(nlnot r¡rlv ol hcr nrurl defórmin,,l)Lrtils() ol llcr
rLnclerprojecring uppcr jltr'. Shc c:rntcin rr'ith hcr firrher,arl orlhodontist,\! h()
\\'iurtc(i¡csrheticcorrccti()11 of rhc risitrlc cvitlcnccc¡f hcr enterior Dr:rrillirrl
ll¡topl:rsie,but r¡,lt /rt.lnr orth(){n.lrhicsurgcrv(he.rirc:rdvh.rclhcr tccfll i¡
_lbn¡irrrl's
pcff¡ct irlignltrcnt). crc.r¡ivcsohlti(n lo this \'¿s ro ¡r¡l¡rncnttl)c crl
tirc \crtical height ofthc trppcr.li¡r bv nricrolirrgrirfiing. lhis loultl trlic¡llv
rcrluirc l0 to l5 cc ol fit, conrplrcrl rvitlt jrrstó ro 3 cc fbl .rugntclltilti()n ()f
thc lermilion pottiou ofthc li¡rs.

^-() l lt: As is thc cascNith rcco¡toUlinq t ltc k^r cr jlw rr'ithnricrofit ur:rliing,rt
is c¡uci¡l to chcck lbr ¡.lc¡t¡l lD¡locclusiollbcfirrcc()frcctingthc dclirrnlit| l¡v
nricrr)fit erafiing. lfthc rrclusion is not r4rtinrel,(r-th()(l()nticct¡rsUIl¡liolt
sho¡ltl bc obt¡inctl. I! rhis clclitnrirv is c()ffcccd bv r¡ic¡-ofrtgrirtiing irntl .r
nr.rxillir\,rLl\'rnccnlcnl is ncccssirrvlrtcr, thc Ii¡rr,rrruklthcn projcct t(x) nntch
enclrvouldbc vcry clil'ficLllt to cor.l.cct,
lrcc¡0scthc fit is i¡tcqretcd th¡.oL¡qlt()Ut
¡ll tissucs.

Hcr posrr4rcretivc
lcsLlltsltorvs.rsir.lnilic¡ltt
t¡.¡nsfi¡l¡¡tioll.

l,r(¡.to 30
 l h c s \ ¡ . , 9 \ ( ) l \ l u l i f x \ l . r l , . r . i . ¡1l { . i u \ c. ¡ r t ( r )t \ r f t i n ! t ¡ . { t L t i , g c u r e r

MUIiflPLEARxAs.Pcrhirpssontc ()f lltc nt()stc\citing irpflic¡li()ns()f lni(r()ftr

grafting:rrc.rt thc c(nrvctgcncc of trollv tilci¡l clcfitnrity ¡lld itcsthcticsurrrct!.
Wc hrvc shr¡rvrrthc usc r¡l'ntic¡ofirtgrlfiing fit pr()li)Lrndr)r¡li1rhrpopl.rsi.r
(sec Fig,.l0 25), firl kxvcr jirrvclclirlrlitv (scc lig. l{)-29), ¡nd fit nrexillrry
h1p<4rhsir(scc t,ig. 10-30). (litscsillUsrfirtin!, rltcscp11)i)lcr)rs in !,fc¿rcrdct¡rt
t i l l b c p ¡ c s c n t c rl rl t c r i l l l t c c h i r p r c(rf i g s . l 0 4 2 . r n c 1l 0 , 1 3 ) .

lVhcn ruulti¡rlccolttoul dclr¡lltitics irrc prcsclrt!ilnd thcsc h¡\c histruiclllv

bccn ch¡llcnliins to sohc, nricrofirrgrirftirrg, c,ul br cspcci¡ll\,\'¡lr¡¡blcbccrusc
i t o f l i r s t h c l 1 1 j t s 0t li o i t t t : l d i s r t ¡ i t i l ¡ t , r l l \ , ¡ t ¡ t \ r i ¡ , a . ' l h c c i ¡ s s i c c r ¡ n t p l c o f n t u l
tiplc c(nlo!¡r dctin'lniticsis l{o¡ttrcrg,'shcnrifircirrl irtrr4rhl'.lrig. l{) .31shrxvs.r
\'()Llnq\!()nrdnNith thc cl.lssia st()rv()fthi( c()Dd¡ on. Ilcr.firci¡l li.ltUl.csrrcrc
n(n1¡¡l thr()ugh¡gc 12, thctr gr¡dr¡itllypf()grcssivc su¡rkcl ilrc.lsdcvcl()pcdin
thc lcft siric ()l l)cr ticc, inclucliogrhc ch¡r¡crcrisric.rrll /. ri¿l? (s¡trcrcrl
d c p r - c s s i ot rn¡ t l r c l c t i o f t h c c h i n ¡ l i r i l i n c .A l l r i s s L r ci sn,c l r r t l i n sgk i n ,s r r b c u l l
r)c()ustissuc.,rrosclc, irn(l lronc..rrci¡tvohcri\\'itll lhc illr()l]llv.

In thc pirst,all sorrsol-hcroicnrc¡surcsrvcfcxttcnrl)lc(ll() lrc¡1 this. incllr(linq

pc(ii(lc(l¡ni rlicrrx'irscrrllrfllps ol-skin,s()titiss!rc.¡¡l(l oltrcntunr.AII ol rhcsc
cflirrtsl crc li¡uqlr¡ l ith lil ntolc coltplcrirv. ntor.cpr.olrlcnts. .rntllcssl)crl¡cl
rcsult\ thir|)rDicrrfit enliing.

ttc. t0 3¡

< *
376 CombinedApproaches
and SyncrshricProcedures

FIG. l0-31, cont'd

The surgicalplan is shownabovc.Becauscofthe extrcmethinnessofthc at¡o-

phicd tissues,only a limitcd amountof graftedfat could be supportedat onc
timc, Wc anticipated and pcrformcd thrce grafting sessionsa year apart to
¡cachour goal. Drawing thc plan for this type ofpatient is quite challenging,
bccausethe surgeonmust c[üsion thrce-dimensionally how to createnormal
anatomyand symmetryfrom theserandom but severecontou¡ defects.Wc
find it hclpful to fust dnw true topographic lines reflecting depth ofthe dcfecr
(blach), ther. to wperimposc the aestheticunis ofthc mala¡ complex and the
chin (green).
 _l
he Sl,nergyofNl!ftimo.talFa.ial ltejuv.m¡ioo: tu¡ring ft A Togcther

FIG. l0 31! cotrCd

Thcsc prcopemtivcand postoperativcvic.rvsillustratehotv r¡icrofht gf¡fiing

carryielcl a bcautif¡i ¡csthcric result tvith nlirrim¡l rr:[rma, cven ir c¡ses ot
lnultiplc sevcrccontoLrrdcfbfÍnities.

Another' exlrnplc that dcr¡onstr¡tes the toru de ftrr.ceachievableby microlit

g|afting lbr multipie sevcrecontoLrr deficicnciesir r purclv aestheticcase
will
be discusscdwith Fig. 10-47.
378 (in¡Lri.ed Apfh¡c|cs ¡Dd Sln.ry¡ri. h).cdur*

Long-TerwSurrital and Stability of Microfot Grafting

Whcn liposuctionwls first intr'crluccclinto Amcricr in 1982, it rvls onlr' ¡
shc¡¡ttimc bcfórc surgeorrs werc tryinu to Llscthc liposrLctiolt
espirltefcrl lLrg
¡Icntin!! srLnlicu¡rc.rs.We lou¡cl ol1lvsp()lxdic,unprcdicteblesurvir'¡l of rc
sults,rnd ol onlv il tilv pcrcentaqcof!,rlficd nrrlerirl.

In l9c)5 (irlcm¡n shon.eclcc¡rclL¡sivciv th¡t lrv h¡rvcstinli I to 2 nrnr trxrticlcs

(thc l¡fqcst th:Ltrlill p]ss unclirrrrgcr.lthroLrqha Lucr Lok s1'ringehub) rrrrtl
using,i1 nlcticLlloLrs tlro¡r b1,dlo¡r tcchniquc fór gretring,prcdicreblcsrrrvivirl
ofr rcl¡ti\cl)' hilih pcrccntirgcofurirlicd firtcould r>ccur.Hc shtx|cclthis usin1{
scri.rl¡hotogr.rphsofscvcrirl¡raticnts,tel<cn.lt pfccisclythc s¡n1c¡11ltlc. ()\'crir
l)cri(xl()fvcirrs.

FIG. lO-32
'l'tr$';.

-l
hc currcnt scr'icsof prticnts confilnls n()r ¡rnh, thc krrg tcrnt surli\'¡l, bltr
thc shl)ilitv oi nricrofit ¡¡r';rfiin¡¡.'fhcP.rLicnrs i| rhis leport.rr-cilr lcilstI vcirr
'l
P()s|(+)cr.ltirc.his 52 lc¡r old rvorlr¡¡ris shown l¡ciirrcend 3Ll vc¡r's¡fLcr¡tr
'l
clrf;rr grrfting to thc ntitl¡rlrc¡. hc r()tltir¡nol'thc hc.rclis l¡ciiflvidcntic¡1()lt
both photos,.r¡c1it is clcrr-th¡r thc lirillrcd lil hlrslot ()nlv sultitcrl, bLrrrc
l l , r . n 'r r i ' l l \ Á i l i , , ) L L l . l r . l . r l r l r r r r ' . . r . .
 '|h.Svnc€y.|¡,1u
¡ i n ¡ n 1 . rhl . i r l R c j L ^ . n ¡ t i o n | u ¡ r i n c l ¡ A L l i J g c d r e r 379

Fr(i. t0 33

3 monlhspostoperalivey

5 yeársposloperalvely 3 yeafs pósloperálvely

'l
his 39 ),c¡r'(ild $,om.rnLrndcrwcnl!l MA(]S lifi.rnd Ilricr'otirg,r.lt'iin!¡ to hcr
lips rnd rrllar ercas.Thrcc montlts postr4rcriltivcl\', x litrlc swcllingis srill prc
scnt.At 5lciusj rhe li¡rsirnd chcckslcmrin firll,;Lncllt 8 Vc¡rsthcr'cis vir-tual
ly no clecrc¡se in thc firllncssofhcr lips,nor of her cltcel(. l hcrc is no pcrccp-
lible ptosisofthc graficd chccl<lit liorrr deie39 to,tr7, dcspitcthc prricnt's
p.rssingthrough mcnopirusc. Wc l¡cl if is s.l1¿to concludcthtt thc f¡t th.rrrc-
nl¡irrs irt I ¡,cirlwill bc drcrc indclinitely,bcc¡uscthc smallplrticlcs arc inlr
n¡tcl| integlatcd in thc rccipieltttissLtc.It is i so clcü that thc gr¡f¡ed f:it is
stablc,nr.rintiiinsits shirpc,antl rcsistsgrlviw ¡t lelrst¡s $'cll es thc nitivc tis
slrc. Thesc chal-ectcristics,:r¡rd rhc lict th¡t it is r'e¡clilyaveilablc,looks end
féelstotallv natur , arrd is el*avs bioconrpatible,makc nicrofit ¡lrafiing:r
ne¿rlr,idc¡lrcsourccfbr acsthcticplirsricsLrrqcons. ln fact,microf';rtgrefiing rs
380 i '{''n.i \1"".(lr'.. ¡r\\,J,!{.. 1,.'.J',,f

ln c\l¡crncll Llsctir¡ tcchniquc:rt thc ()tlrcrend ()f-thcspectrlrnrlirr l.rrgerr)l-

umc lr.rg¡Dcnr.rtion. lhc scrrior¡Uthc¡rh¡s orreofthe l¡r't-¡cst sclicsirr LhcF.rr-
lish l.rngue¡¡c Iiterrt!¡feol-iuqn)cntaticlrr ()fthe Lruttocks[¡r n]icrofhlg,laftir!,.
.Llrrcnily rD()rethirn .J50citscs.Ilr this .lfc¡, tltc ¡bilit| t() rrot onl| iruunterrl,
L)ut:lls()t() crcite ¡ f¡lnir)incshir¡cNhcrc therc \\'asn()nc,to litcrrllv r'cscrrl¡t
thc t(r'so, .lnd to h¡rc thc shipc list xs lorrg ls if it \\'crc thc origin.ll b()dr
sh¡lc. is ¡ lrifi no r)flrcrpr()cedL¡rccirn ()fter.Arrgrrcntrtion of rrp to 1000 cc
l)cr bultock is routinclv|crfirrrDccl,irnd r|c hlvc photogrirphic(l()cuorcrlt¡ti()n
()f thc volunrc lnd sh.4rcrcnreiningülahingcd in scvcr'irl pirticnts¡t()\r up l()
o |cirrs Post()l)cr¡lr\clv.

Complementary Procedule 2: Laser Resurfacing

lVirll nlicrr¡tiltgr.rfringwc h¡r'c thc irbilityto ¡d(l r()l!tntc¡rtl colrtoLrrto our
lici¡l sculltLrrc.Iirt rr h¡r ¡borrt thc qu.rlitv()flhc suÍlicc thc cflicts ofirgi¡g.
¡url sol¡r rl¡rrr¡sc()rrthc sl(ir),thc wrinklcs,crrr¡rincss. ¡¡tl spkrtcht'Iig,¡rcn,.,
lion¡ llcfi)rc 1993, Phcnol Pcclswcrc ¡viril¡Lrlcirr rvhichthc rrciLlwils ¡pplic(l.
thr licc \'.ls c<xcrctllith tipc ()r thun()l ir¡rlidc,thcn thc surgc(nrprrlccl li,r'
2 \\ccks thdt thc tiri¡l skin rrrlr[1 rcc(^'cr.It Lrsuillvr]i(1,irnd ¡ l()t ol thc \\r'ir)
klcr rcrc er¡rc, lrut thc skin:rlrr'¡r's bcc¡rucgh()s(l\'\\ hilc. It rlits irll or rrorrc;
lhctc rr'¡sno in trc¡rvccn.

'I
lrr:nOb.rgi intrrxlLrcccl ('l(]A) Pccls.lt \\¡s c¡iirrc(l rlr.l
tichl(lt.t)ilcctic.¡cid
'l(lA
ollircLl conlollittrlc tlcurccsofrlcpth of¡rccling.tirr crrnrplc, lry rcl]ing
lhc (lcgrcc of ./iovlz4 ol thc skin ¡nd thc prcscncc()r.lbscncc(f r?i//a,?r/r/
r/l/lrtr¡. HoNcvcr, thcrc \\'xsir fl¡\: thcscsilins\r'crc.tlctlurrtclirr jur.lging, sLr
l)crfi(i¡l Pccls,l¡rr1thcre rr'¡sno r\.lv ol knorvingrr ith .r ticcpcr pccl rr'lrcnthc
lirlc h:rd bccn c¡osscrlfionr u¡rpcrclcrrnisLt)(lccp clcrDis,.¡,1!l lhc incfc¡sc()l-
hvPcrlrt4rhicscllring u'ith thc dccpcr"l(iA |ccl wils ulilccc|tilbh, high.

Irr 1993 lhc scni(n iluth()r bcgln hc.rringrlrnl()rs¡h()tlr:r lrrscrthrrr co ld

"cr¡\c \rfilklcs." I visitctl rlcrnrrtologistllich¡rd Fitz¡r.rrlickin S.rn l)icgo.
rr'ho h¡r'l cione thc ¡rionccrinurxrrk rirh rhc (l(), lrscr, rrntl hc gcncrouslv
sltirr'crl
his crPcricncctith nrc. I Lrcg¡r¡trsinqrlrc llscl on sonrcofnrv Pirlicnts
.urrlrr'.rsvcrr irnplcssccl
¡lrt orh rr ith its ¡trili to ¡rini¡rri¿crlri¡klcs, brrt .rlso
wirh the rlcgrceof corLr'olend plcLlicLlbilitvit ofllrcrl. I nr¡¡.lcthc first pfc
scDtilti(nr()r)thcc()rrcc¡rtoflescrrcsurficinetoourspcci.rltv.rlthcl99Slnecr
inc of¡hc ¡\nrcric¡nSocic¡ iirr Acsthericenrl l)lltsticSLrr¡r,clr'.

Al¡lost sinrult.rncorrsl\'trrrtscprrrirtclt,
J.rv13rrrns
¡nd llrrxrkcScckelllso rccol¡
nizccltlrc ¡rotcntiitlrolc ofthc (lO, I¡scr fiu lici:Llrcjur.crltion. lhc oliginrl
clcricch¡d orrh ¡ Inrnl¡itlh¡ndpiccc,Drrki¡rllit c\trcrrlclr o¡rcllor clc¡rcntlcnt,
irtrcltcports of htpcrtlo¡rhic seirring wcrc n()l Llnc()nrnr()n- Horvcvcr,lhcn
(i()- litsersur'gcrrlirs donc pr-o¡crlv,thc rcsrrltscould bc rcnr¡¡katrlc.
 'lhc '1i'gcdrcr
\ \ ¡ . , 1 l \ , n \ l u l r i n r \ 1 . rl1i . i . r l I ¡ . . i u \ r n ¡ t i , r rl u
: ri¡s It .\ll 38r

FI(I.

'l
lris 7(r vc¡r oLl l).lticnl \'¡|' l)rcscnlcdli\c ilt ()llr first tcircltin,tc()rrrsctn
1 9 9 5 . l h c p ¡ t i c n l h ¡ d L n c i c r q o nlc( ) t i t l i c i i r ll ¡ s c fr c s r ¡ r i i c i l l¡rn¡ d s i ¡ ¡ r r l t l n c
¡rtrsficc lili .rnclblcPh.rrr4rllstr -l r¡ortths
¡r'cvioush.Nr¡ ¡¡hcr ¡cchrriqocc\
( e p l ¡ p h c n ( ' lP c c lc r r r r l thi ¡ r c c o ¡ t c ( l ( ) s cl ( ) l h c s ( r c s U I t sx.n ( l n ( ' ( , n c \ ' ( ) U k l
t l . r ' ct o r k r . r t { ' l . r lf i r c i r ¡l r h c r r opl c c l¡ t t h c t i n r co 1 ¡ l i c c l i l t . l l t o s c r r l l o s ¡ r r
lrcl in ¡crson r.rpirlhcntcrctl thc tnlot plttrtt.Iicc.rtrsc rirtl¡lh .rll ol r¡r c.rrlr'
l.rsct¡itticnLswcr'cfiril sl<inncrl lor¡cn in thci¡ filticsto sclcnlics.thc IR)t)lcnr
ol hr Popig¡¡¡¡ 1¡¡i1¡rilitl not bccoltrc.¡Pl)i¡l'cnt ultil ¡l¡ou¡ ¡ r'c¡r l¡¡cr, rr'lrcn
(
t i r l l o l ' i n gt r p ¡ n r ¡ n \ \ i l h f i r i r l rc l i r r l i l ¡ u c ¡ r i ¡ ns k i n .H i s f c s u l tr r r s p l c r s i n u . r t
ó n r r n r h s ,b u t l r v l 2 r D ( r ] l l 1 h s c h . r c sl l i g l t rl i g l r t c n i n gr ¡ l h i s s k i n . I l v l l l
nr(nrths,his skirrrr'¡s ¡lmost .ts \'ltilc ¡s rficr ¡ phcrr()lpccl. licc¡usc ()f rhis
hypopiqrlrcntirtion¡r(l thc l)()fcntiilllirr hypcrtrophic sc.lffio$. Nc L)carlltc
!)1t¡chlcssuqrcssi\c in our |csurficinq.Sc¡rring Lrcc.rntc ir nonissrrc,.rnrl thc
ht'Po¡rigrttent.rtiorr rr'¡stlccrc.rsccl l{) i¡n icccl)tirl)lcIcvel,il ¡hc lrorrnr]l¡icso1'
fcsurticir)l¡\\crc t::rthcrccl.'lhc intcrsc crrthcnr¡ (think l()bstcf)¡rficn hsrcrl
ó t ( ) I 2 n r ( ) n t h s¡ n r l r r l s d i l l i c t r l rl ( ) c ( n c c ¡ l ic v c n t i t l t n r i r k e r r pl h . ( ) s c\ \ t t ( )
()f
\\'crcLl()inrrnr()st thc elinic¡llcsc¡lch rr'irltt ltc ), llscr' J:rl lltrr-ns,llrrxrkc (l( (
Scckcl.(lnrhiir Wcilstcin of ALrstr'¡li.r. (i.rrv lbscnbcrg..lnclnrlsclfl t¡lr lh¡r
lhc dcsrcc ofcr'r'thcnr¡\yilsncccsslry¡o obr¡in tllc strikiltq rcsultsoftiqll¡cf.
rlr(x'ccl.¡slicskin.Sonrcrvcrccr¡rcrirrrcntio11 \\'ith thc crbiunl\'.\(i l.rscr'. rr llich
Icrs
cirLrsccl cn thcnr¡. lrLr¡¡lso lcsssliin tiqhlcnin!!.

'lltc
Sciton tlu¡l nrodc crbiLrnlYA(i lrrserlrr: dclcl<4rcdro ¡chicrc ¡hc s¡lrrc
\ \ l i n k l c c f . r s i r rc! l l L c t¡ s ¡ h c ( l ( ) . l l s c r .l ¡ u t r r i t h h r r l f t h ci ¡ t c r r s i t to f t h c c r - v
thcnr.l(lliok insleitdol lrbstcl lccl),.rndlitcr'¡llvh¡lf the rlu¡.rrionof cnlltcln¡
(th¡t is, I f() 3 nrr¡rthsinstcltl of(r to l2 nronrhs¡.fhis ¡.lcticc(()nlbitrcsf\\'()
cr'[¡iLrrrr:\'A(] l¡sc¡s onc tr¡r'¡trl¡tir¡n¡ntl olc ii¡- hc.rtsltrinliins\\'ith irn rrl¡r:t
342 CombinedApp.o¿chcs¡nd Svn€rgistic
P.occdu.cs

long pulsewidth. This laseropered ¡nanynew possibilities,especiallythat of

regionalresurfacing.The CQ lase¡createdso much rednessthat if the sur-
geonattcmptcdto resurfacca¡oundthe eyesand mouth, tie alt€rnatingbands
of white forehcad,red cyelids,white checks,red mouti, and white neckwe¡e
impossiblcto conceal.Howevcr, üth the Sciton, the mild pinknessand its
short durationmadeit feasibleto do regionalresurfacing.Now, after over 12
yearsofexperiencc,the ¡ole oflase¡ ¡esurfacinghasbecomeclearer.

Laserresurfacingis rarely used by surgeonsas a stand-alonetreatrnenr,al-

though somedermatologists do this.The most common applicationis perior-
bital and/or perioralresurfacing,which arc the two arcaswherc most f¡cial
wrirkles arefo,und.l,ascrresurfacingis uniquelyeffcctive(ard unequalled)fbr
rejuvcnatingthc pcriorbitalarea,which is the thinncstskin on rhe bod¡ oftcn
in the rangeof 300 to 500 microns(0.3 to 0.5 mm). Becauscthis lascrc¡n
rcach a depth of about 200 to 250 microns(ovcr half thc thickncssof thrs
skin), it givesremarkablctighteningofthe looscskin aroundthe cyelids.The
periorbitalskin is of'tendark,asseenin Fig. 10"34,,4, and this is the one place
a littlc lightcningolthe skin is dcsirableand not a problcm. O¡c canscehow
much bettcr thc pcriorbitalskin is in Fig. 10-34, B, bodr in texturc and color
matchwith the facc.With mininal feathcri¡rgofthc edgcs,therc is virtuallyno
demarcationaroundthc evclids,

FIG, 10-34, coDt'd

In oldcr patients,nalar bags¡rtd festoorsn'ny bc present(secFig. 10-34,,4

and C), and thcre is no rechriquerh¡r ca¡ come closcto the laser'sability to
irtprove or elinrinatcmalarbags(seeFig. 10-34, B and D). The amountofen-
ergy (Joulcs/cm')delivcredto tl'rc skin is complctelycontrollable¡nd affecrs
only the top 250 microns,so it is safe(in expericnced hands)over undermined
skin,which meansit canbe usedsimültaneously with crdobrow lift, blepharo-
plasty,a¡d even(conservatively) a facelift. As mcntionedpreviously,no othcr
 lh.Sri,rigrt)f,\!!tLn¡odrl l¡r,, lLeju.¡ri,¡,: l,ur¡i¡! tr AI t.gc¡h.r 38.¡

rcsLrrficingr1r()d¡1iñ(phclt()ll)ecl. l(lA pcel, (n dcnlrilbrilsi()n)c¡n bc used

Nhcn thcsesrlrgia.llpr'()ccdrlrcs¡fc donc. lhis n()!r nrcilltsllt¡t ¡ p]ticnl c¡r1
hrr c corrr¡rlchcnsivc
ficill rcjLncnrtion, irrclLrrline
rcjLrrcnetion of thc sliirr,.rt
()nc slll]l)lL

t r t c ,I 0 3 5

r-5;.y''

lircn lirl err-lirrgirrschilnllcsrr()utrdrl¡c erclirls,.iLrch¡s th()scscenin thi\ .j9

rcrrr oltl prticnr, fhc l.lscfpl¡rs rn irr-c¡rl.tcc.rLrlc
rolc \\rhcl¡ eomLrinccl rrith .r
l(x\cr'tl.utsc()¡juuctiv.rlblcph.uo|l.trtl lnLl r lifflc nticrolif !¡r.lfiinqto thc tc.rr
tnrLruh,tlre l¡scr ÍcsLl-f.rcinq rr¡lics hcr Ixrh 25 or.30 -fhc L)lcphrfol)l¡\tl
rlonc, ol contLrilcrlrvith lt¡icnrf.rtqr.rfiinq,could not hrvc h¡(l rhis ettlct
\ ith()ut rhc lilscr.
384 CombinedApproichesúd Synergistic
Procedures

AestheilcProblems SurglcalPlan
Eyeslookiir€d(crépsy,line
wrinkl€s) FouFlldfansconluncl
valblepharoplasiy

Earyaging:Th€ id.ch€skjunciionis Periorb tallas€rr€sudacing smootlros

and
vsbe andappar€nlh€ighlol lower giv€syoulhlLrll€xturoto skinandobsc!ras
rh€lld-ch66kjuñclion
S Ighltaciala¡dn€ckbxry ¡,¡ACS-ift

The periorbitalareaofthis Sl-year-olclwonan hasdevelopedcrépe¡ redun-

dant skin iu thc upper lid, widr wrinklesin the lower lid and crow's-fcet.The
apparentheight of the lower lid is beginningto increaseand the lid-cheek
junction is becomingapparent.There are alsosome early dark circlesunde¡
her right eye.

The blepharoplastyhelped with the loose skin of her upper lid, and the
MACSJift with anteriorplatysmarepairgaveher a crispneck andjawline,but
the laserresurfacingoutlinedin Fig. l0-3ó, B, gavethe fresh,sparklinglook to
her eyes,eliminatedthe w¡inklesand darkcirclesunderthe eyes,and madethe
lid-cheekjunction imperceptible.
 Ih.s\f.¡q1,n \l![jjrrnl¡L F¡.j]l ltrju\rrú(n,: l\rrin! Ir ¡lL li)q.rl)rf

!rG_ l0 37

'.i¡., -...ñ
ür-

d
'l
ü. .r
,$ x
hc pcr'ior'bit.rl rcg,iorrof this (r.3-r'c.r.olcl rl.rr crhilritsnrrlc :rt1r lncctl siqrrso1
( ) l
r g i n g ,i n c l L r t l i nlg) t ( ) s i s l h c b l o l s . c l r r s i n et l t c L r ¡ p c rl i t l sr o l i t c l ¡ l l vl t . r t q
o v c r ' 1 h cc v c L r s l r c sl h. c c l c c ¡ lri ; r c l t c . t tl il l t c ss l t r ¡ vt l t . r rh c l i c q r r c n t l ll r . r st o
r - l i s cl r i sL r r r ¡ r rt o
s c l c . r r t h cr r P ¡ r cl irc l r o l 1r ' i s i r r nl .h c t ¡ ¡ l ¡ r l i t l t ¡ sb c c o l r r c . r t ¡ o
¡hic lntlfrr l)t()tic,c¡usiu!¡,¡ l¡rqc. r'irlc lc.rl troLrglt.()n lrrtcr'.rl vicl, tnc
nr.rl¡r'ficirrl qr(xrtc c¡rr l¡c clcur-liscclt ls.t rlclrrcssionoitcntlirr!l (lo\\lt\\.111
l i o r ¡ l t l l c t e ¡ r - t r - r r L r qb hc .t r r c c nt h c n r r r l ¡ cr n r i r c r c c¡ n ( l f h c n { ) s c .l h c c v c l , . ,
L t ¡ g s¡ r - cI r ' o t r o u t t c c .Hl .c i s r c r \ l i g l r ts c n s i t i r c . r ns, lq L r i n t¡s l ( f t c h r . r ) r r(i)cr
LricLrl¡o r icsu l i. ( ) n l r i r c l i ( ) ¡ r) l, l l i c hi s t l t c e . t u s c , r f r h d
c o z c n so l - t f u c ¡r r r i r r k l . .
( ) u t
r ' ¡ t l i ¡ r i n e t h f t ) o ¿ ht h c L r I P c ¡r r r r ll o r rc r 'l i L l s¡ n t l r h c c r t ¡ r r ' sl c c t r r r c ¡ .

'llrrrlition¡l
lrrr'qclvcou[1 nrrr ¡rossiLrlv h.rvcpnrdLrccdthc crisl),srrlx)th c\c
i o n c ss c c n( ) n l i l l c r ¡ lr i c N l ! c . r l p o s t r 4 r c r ' ¡ t i \ c lI \u' .¡ J d i t i ( ) nl { )
l i t l s ¡ n r le h c c l b
blc¡rhlr-oirllsn,hc rcclLrircd rlricroli¡ larrtiine t() rhc rcrr rrrtruh. nt¡l.r'lici¡l
u,r-rrlc, rntl chccl(Lx)nc!,¡rrd l¡scl resLl-ficingto snt(x)thit ¡ll rilr lt. A lrinr
nr¡l cndr¡l¡r'r¡vlili lr.rs¡crlirlrrrerlto Lrnlo.rrl rhc Lrppcllitl.
38ó CombinedAppro¡che.¿ndSrrersstic Procedures

Total Facial Lnset' Reswrfocing

FrG.r0-38

Ae¡lhqllc Probl€ma SurglcalPlan

DoepfoÉh6ádllnssoaus€dbychro¡ic Endobrow
llfl
lrontallemlecl€ cbñtracton lo cloár

Mic¡ofalgrati¡g to ñlrablow/upporlids,fown
Holow upp6rllds I n€8,t6aflrcugh,malárlácialgroov6,
Mlldi€arroughsandmalarlaclalgroov€s maion€tleI n€s,andlaio|alchin
Laokol malarprojsoiion rviorofalgraningfor augm€nialon ol ch€sk
Dé6pmalonétt€lln6s boñ€sándfps
Thlnllps
Lateralchlnnoich
Mildjowling ot jowlsandn6ck
¡Vinofliposuction
Faclalandc€rvcallaxlly
Plaiysma bandlng l\,lAosllfi wlih ani€|iorplatysmar€par
coars€skinwlthlarg€por€s
Facialrhylids, Totalaciallasorresurlacing

This 52-year-oldwoman presentedwirh sun-damaged rkin and hcd deep.in-

grainedwrinklesin her forehead,multiple long crow's-feetwrinkles, and a
coa¡selook to he¡ cheekskin,with largeporesclearlyvisible.

The treatmentplan includedtotal facialresurfacing,alongwith an endobrow

lift, microfat grafting of the areasshown,and liposuctionof the jowls. Green
signifies areasfor grafting, ral for liposuction, a¡d bla¿hot¡t\nes the area for
lase¡¡esurfacinE.
 Thc Synergyof Mtrhimodallacial Rejuve¡¡rion:tuttiDg Ir AU Tógcrher 347

FtG. l0-38, cont'd

Thcsc treatrrcntsgavehcr ir youthñ¡l look I yearpostoperarively with ficshl

clcar,smoothskin amclfull lips.A full flce lift rvasperlbrmcdto treat her rcckr
jowls, and jarvline.
388 Combnl.d Afpú)¡.her md SvncrSisric
l}ocedurcs

FtG. I0.39

Althorrgh this rvomrn Irrcl nrultiplc signs ofaging (trrorv ptosis, ficial rnd ccr-
vicrrlhxity, jorvling),hcr clonrinantprotrlcnrlvasscvcrcingraincdwrinkling of
thc cntirc fircc.A firccIilt nnri ncck lift ¡lonc could llcvcr h¡vc givcn this clc¡5rcc
of irn¡Trovcmcnt; olrly tlrc aclditionsoftot¡l fircialI¡sct tcst¡¡fhcingcould havc
giYcn this rcsult. Convcrsclv.rcsurfircing ll<>r'rc\'oultl firll shoft oftlris rcsr¡lt.
Thc svncrgyofall hcr proccclurcs Irm givcn lrcr;r tlrirnri¡ticbut nrturll-l¡rpciu-
ing fctuvcuitiol.

Il"vlgc ó2, thc paticrt hird dcvclopccll rinklcs¡ll ovcr hcr ficc. Thc mgirc on
hcr u¡-rpcrli¡-r,fbrchcrd lincs, fiorvn lincs, crou¡s-f'cct, rv nklcs of rl'rc u¡r¡-tr
antl los,cr c,vclids,¡ncl cvcn thc clrccks irncl jorr'ls lucl ilgrainecl rvriuklcs. No
lmount ofpulling vi¡ fircclift coulcl(or should) [¡c ¡blc to smooth thcseou¡,
[¡ut lvhcll cor¡bi¡ed with tot¡l fici¡l lirscrrcsurfircing, li¡rosuctiouofthc jowls,
ancl ¡ b¡ ow lift, the rcsult is a sprrkly look ¡¡¡d tlrc skin of a *'o¡¡irn 20 r,cars
youlgcr (not o¡l,v with f¡$cr wrinklcs,but morc t¡¡ifirrnt in pigmcnt¡tiur).
1_vpicall¡,s,ith the Sciton hscr, sc Lrscnrr cnerg_v dcnsit_yof20 Joulcs/c¡rr. Thrs
lascris ¡lso c¡libratccl to sholv rhe clc¡rrhoftissue bcing trcxtcd. Thc pulscsrrc
¡hcr¡lirtcdbv r revolvingnirror. It ciln l¡c sct for cithcr ¡bl¡tion ()r co¡gúlir
tion (hc:rt-sllrink), or d conrbiDatidr. Wc gcnerall,vL¡scit¡t 80 Ínicron dcprh of
ablatiol. Oonbining this dcpth rvitlr 50 microns of coagulationhcl¡rsmini
mize blcctling and givcs so¡nc hcat-slrrink ef]'ecr.T()gcthcr, thesc pirrimctcrs
'l'hc
cleliver20 foulcslm:. third ¡¡rcl fi¡rll ¡rarirmctcris ¡rrrefit o1'¿t'ldp;50o/o
is
 'lh(
S \ D c r q , f l l n l r i m o { l . r lt ¡ . i r l l l c ¡ ! \ e ¡ . ü ! D : | t r r i ¡ s l ¡ . \ l l T ( ) S ú h 3Ít9

en()Lrgll unifi)rnrcfl¡ct ¡nd ¡v()iclpittcfn intprinti g. (t.\t lt()¡-: Rcsr¡r'

to 1.¡iYc
fácin¡lolcr skin th¡t h¡s l.lccno¡ rrill bc u¡rlc¡-rnincdnrust be .(nrscr\'.rtivc.
usu¡llr onc prss ¡rosteriorlr'(thcr'c arc gcncralll no or lcl inr¡r¡iltctllrinlilcs
in thc ¡rosteriolhlll ofthc chcek,so lirsirruItcr-cis printlr-ill r{rnc to lcllicre
color blcnding).c:.tL¡llox:Llsi¡g ()nlr onc p.rssolt.lll .lrcl c.ül fcsltlt in /¡,r/-
xrt in printir ¡, ttith i¡dividuel dots bcing visibleon dlc skin. (icncr'¡lh, rhc
scc()r]dpassblr¡fsthc inrigc ()l thc lilst plrss;this is onc rc¡son tlt¡t l.lscrrcsut
iircingovcr unclcrminecl skin shot¡H n()t lrc urrlcrtirkcnuntil ()rrchilssiqnili
cant cr¡rcricnccsith trc.rtnrcnt¡ntl klrg tcrnt frrlkrn u¡r.

Thc rugeein thc Lr¡r¡rcr li¡r rcqr¡ifcspcciil rflcntion: bcfirrcrcsLrlfircing thc li¡
Nith thc conrplrtcr'izctl ¡r:rttcrnrcncrltor, \vc !tscthc nt.ln(¡¡lh¡¡t(lpicccNilh r
purc ¡blxtc scttin!,to sculptdo\rt thc sh()uldcN()fthcsc ridgcs:this nr¡r'r¡rl.c
scvcr¡lpirsscs Nirh the nlilnuillhitndpicccjs()fltc pilticntshould lrc rvlrncd thlt
c¡ch firrlou * ill h:rvc.r piriI rrfvcrfic¡l pi¡k lirtcs$icrc thcv wc¡c l¡scd tt¡vn
th¡t \rill str\'fiDk nruch krngcr thirn rltc lasctlskin in gcnclel.Aticr hsing rhc
ridgcsclo\\'rrt() thc lclcl rf thc sLrrliccof thc liP, onc (r- t\\r) pllsscs¡rc t1t.t(lc
\\'ith llrc conrputcrizctlPrttcrn gcncrrror'(Ol'(i) if ¡ddition¡l s¡t(x)rhinLlis
ncctlctl firr thc rcst of thc lip. c,\t'lr()\: l'hcrc is no visrr.rlcntlpoinr lirh rhc
crtriunr:\A(l I¡scr. ¡ntl r¡crzc;rkrosPLrrsuitof tllc rug¡c (iln Icsltlt in hvl)ef
tf()plri( scirrinl¡.1o \vlrichthc LrP|cflil) is csPceiirllr,st¡sccptiL¡lc.lVircncrcrthc
surt¡conrlccnrsit ncccssrrrtl(' (1()rr{)rc.lgl.ltcssi\c fcsrtrti(inq,ltc (n shc tDust
lclclrhcsc¡rc.rsrvitlt b¡r'c Iilt$c¡ tips trricc:r lcck Ii:r.3 lccks, kxrkirrqirr'.rrtl
¡rc¡ ol'firnr¡cssthitt nright strggcstincipicntsc.rlring.St¡cllfir'¡llcss,il'firunrl,
slrou Lrcinjcctcriinrnrcrli¡tclllith trirurcinokrnc.l his problcnris .r r¡r'coc
currcrrec,rtntlthc rcsr¡ltssh()\\'nin liig. l0-.39. ./l,.rrcr'cll rrrrr'ththc s¡t:rllIisk.

Complementlry Procedure 3: f udicious FaciirlLiposuction

llcfin'cthc lrlvcnt ofruto|:grxrs firt gr'.rfiing.srrrgcoosrlclc ¡firitl trr ¡cltirrnr
lipostretiorr (n thc ficc tirr lirr ol c¡Llsinqirlcvclsilrlctlcpr'cssiolls. t\r)\', h(n\
cver,Lrcc:trrsc of irrcrclsctlcrpcricnccs ith jLrrlicioLrs ficiirl li¡rostrctionrntl rli
crofit er¿lii¡lg.conscr\ilti\cliposucti()nwitlt it hlc ci¡ltnul¡ll.5 to 2.5 nrnt cli
enrctcr')is e tcchniqucc¡)rl)l()\'cc1 b| nrirnt'acsthcticpl.rsticsurgc()ns. cr\Lfrr()Nl
Frciitl li¡xrsucion (rltirt is, of nrctli.rlchccks.rnrlfrr jolls) nt!rstbc pcrfi)fnrc(l
\'ith ¡ svúngexn(l n()t.r nrirchinc,s()th.lt prceisc¡treilsurcntellt ()fl.l1t-cltt()\'c(l
is ¡rossible. \lt usc.r 50 cc svrinsc\\ itlr ir sirr|lc I()ckir1{(lcriccto holtl thc lre
Lrurlr.( ;\l:t t()N:IL is cruci¡l ro knol' tlrc volur¡c ol tirt r'cnrovccl anrl n()t just ()l'
the ilspirilte.It thc rrspiretcis blxrclt',rvcccrrtr'ifirgc ir tc)kn()\vthc c\rct .rmoul)l.
390 ( l{!, n,üi d , \rr,¡).'.h.\ .uni S\ nug¡ri. l¡..rdui $

tl(1. l0 .10
B

G\,
;

Ptr
&

I 1o ¡ r cs i r l c< ¡ lt l r c 1 ¡ c ci s s r r ' ¡ r l l corrr- c c c h v n r o llilco n r t h c l o c ¡ l . r n c s t h c t i n cjcc

t i o n , t h c o t h c r s i d cs h o u l t lL r cl i p o s L r c l i o n lci d l s l t o r l c r c r ¡ r i n ct h c \ ( ) l u n r c( ) 1 -
lit to lcnrovc to qilc lhc ticsircrl.rl¡Pc¡rrrrrcc. lt nr.rt lrc irslittlc rrsI to 2 ec or
. t sn r u c h. r sl 0 c c P c l s i r l c ¡. s i n t h i sn n n . ( l t ' l l () \ : ( ) r r rs h ( ) L r ln¡ c l c l o r r ' . r r c l r
l i ¡ o s L r c t i r .rrnn vl i r l d sj t r s tl . r t c r . tl l{ ) l h c ¡ r ' ¡ l c o r l r l i s s L r r - cl hsi.s s l i i ni s t c t h c l c t l
t o r l l c u n t i c r l v i n cn r u s c l c s¡ n. r l I h c f r f h c l \ \ ' c c rl rl ) c s cl . r l c f sp r o v i t i c s¡ . r t l t l i n g
to l<ccPslii¡rlirll .urrllilnr. In ¡rlt1i¡ion.p.rti¡rrrfs h.r\ln1.l.r ficc lili olicn .rllc.rtll
h¡rc sonrc llritl r¡l'thc sliin l.rLc¡¡lf() thc c()r'ncrol thc nrorrth;¡hcrcfirlc.i1'
c v c n¡ s n r ¡ l li n r () L r n(l ) l t h i sJ i l i s r ' c r r r o v ctdh.c r ' c s r rilrtl ic l s l c l l i n gi s g o n c n r i r l
b c s c r c r - r lc l r n ( ) t i r e l L ) l rc) ( ) sfci r l t l sl r t c r ' ¡ tl ( ) f h c u r ( ) u t hr. r h i e hr r o r - co r - l c s s
prlrllcl rhc n¡sol¡l¡irl tir|tl. llris is ¡ r'c¡l rlilcnrnr.r,Lrcc.rrrsc ir is Lrnlikcli¡h¡t
cvcn r sccr¡rrlticc lifi will inrplovc rhcsctir[1s;ucnclrllt'.(rnly r]ifcct c\cisi(rn
o f t h c I x r s c s k i n ( \ \ i t h t h c s c r f p l ¡ . c ( l i n t h c c r ¡ c t l o c r t i o no f t h c n ¡ s ¡ r h b i ¡ l
fi¡lr])rvill lctlucc rhcnr, bur rl ¡hc r()sl ()11hc visil)lcsc.u.It is clifliculttr¡ rc
s\orc thc ltrt:ltitLn litrtli0]t ol tllis lirt L)\ r)ri.r()firitfrliiülr.
 'l¡BerhLr
l h ( \ r D L r S t' n I l ü 1 , ñ ¡ ' ¡ r l l N , ¡ l I ( L t ú f ( ¡ r h ' ü . f u r r i n Él r A l l 39I

FlG. lo-4t

Ae3th6tlcProblems SurglcalPlan
Ha|shorcriiicallooks€condarylo
frown Endobrow
lft wirhcorugarorrosecrloñ
llñ€sandbrowptosis
Laserr6sulacingof upperp€no¡bilal
arۇ
Lossot doriniiion
ol ch€ekssscondary
lo Liposuctlonoljowls
hoavyjowls Noche6káugm€nlállon
Thiñlowerlip M¡c.olalg.allingto lowe¡lip

This 37-ycrr-oltllvc¡m¡nis ¿n iderl c¡nditlrrtctbr jrrdiciousIiposr.rction,¡ncl il

lirct, thcrc is no othcr goocl rvay to rlc¡l rvith thcsc hcirvy mcdill chccks lnd
jowls.1hc füllncssofthc jolvlsis hcr milin :rcsthcticproblcm, rvhichnrlkcs lrcr
kxrk hct'1,and l¡lunt irr hcr jal'linc, olrsculcs hcl checks, irnd nr:rkeshcr fircc
l(xt( squ¡rc.

Thc harslr fitxvn lincs ¡nd hc¡vy brows rcqr.riredan cndobr<xvlifi, irnclshc also
rr'¡nted ¡nore fi.rllnessi¡r her lou,er lip. Gr¿¿zindic¡tcs ¡rcxs tbr grrrt'iing, rel
firr liposuction, irnd lrla¿áoutlincs arc;rsf-orlirserrcsurfirciug.

Tltc rcsult ofthis conrbinatiorr ofproccdurcs is sturtning, lnd sho\ys thc porr-
cr of crrcfirlll, ¡rcrfirrnrcd l\rosuction as a tool fi)r scr pting thc ficc and in'
proving its pro¡rortions. No chcck augmcnt¡tio¡r wirsdo¡rc; tltrlv li¡rosuction rn
tlrc ¿reasi[dic¡tccl.
CombincdApproáchcsa¡d S],rergisriclrocdurcs

FIG. lO-42

Aesthetlc P.obl€ms SurglcalPlrn

Unn€c€ssarybrowslevalionand fo€hsad Four-lidbl€pháropr6sly
wri¡kling36coñdáry
lo sup€nor vlsuallisld

Lal€rálcánlhálsusp6nsio¡
Lowerlidbagsandwinklss Lss€rresurfacingol p6rioóitál ar€a
MicblalgÉfiñg ror€arrough,ña¡ararea.

L posuclionol ñ6dlalch€6ks4owlg
Nolchño g l m a ¡ d b u am
f a r g na t a i 6 € l c h l n Mlcrolálgrafll¡g1oEt6ralchin
nolch
Facialandc6wicallax¡ly

At thc othcr end of thc spcctrumis rhis ó3-ycrrr-oLd r¡:rn, Hc clislikcclhis

jolvls, but alsohrd a hy¡roplastic
zvgonu, which g¿vchim dccp tear trollgihsl
no chcck projcctiol, arcl ¡roor sr¡pportfor his kru,crlids; his i¡ferior orbit¡l
r¡nrwasalmostl2 mm posteriorto thc cornca.This l¡ck oflicl sr,rpportalsoled
to sclcralshow)¡rndhis shalloworbirs gavehinr l bug-eyedor cxophthirlmrc
¡ppcaranceth¡t hc dislikcd.The dccrc¡sedsu¡rcriorvisualficld causcdby his
rcdund¿¡rtuppcr eyelidscauscdhim to constantlvhold his brou,sclcvatc<l.
This, in turn, cruscddeepcreasingofthe fbrel¡c¡d.cxutloN: A lorvcr blcph,
:rroplastyalonc could crc¡te three problcmsin thc prcsenceof shallo*,orbrts
and prccxisti¡C!scleralshow First, rcmovalofany lorvcr fat could rcvc¡l the
colttour of thc globe morc and incrcascthe lrug-c¡,cdappelrancc-Sccorrd,
scler¡lshowtrrav$,orsen,cspeciallyifany skinis rcscctcd.Lasth,,ifr tr¡dition-
¿rlhorizontal licl shortening¡rroccclurcis donc to treat thc sclcralshorv bc
 l l , . S \ r ü g \ ( ) f \ i L i l ( i f r t r L . ' l f . , . i rl tl . t f \ ! ¡ ¡ ( r , : t , r r L i n g l ¡ A l t l t ) ! . L h . f .19.3

ciLuscthc lid is ¡lr'c¡cl\l¡cl¡¡trlhc cqLrrtorofthc globc, simplr shorrerri¡q()l

tigh¡cni !! tllc lotrcI lid \\'ith()ut¡n uP$.erddlsplirccntcnt of its poirrt of sLr¡r
Port i l h e L r t c r ' ¡
c l i n t h u s )\ i l l r c s u l t
i n ¡ n c \ r l t l ( ) \ \ c r
l .
i r l p o s i L i o n( t h ¡ t i s , i t 1
crc.rscdsclcr¡l shoN lncl err4rhth¡lnlicill)pcrr.lrlcc).This siru.rtiolrrcr¡Lrilcs;r
l.rtcr.rl crrrrthr4rcrr', u lticltrrc l jll tliscuss slttrrtlv.I lis surgicll¡rl.rrtrcqLrit-cd :r 1i.,,
1¡ccrnrl ncck lili Io dc¡l l ith ¡ltc l¡rgc ¡nt()ulttol l(¡)sej(^\'l ¡nd nccl(skirr.

r_l(i.l0 '12.ü'rr'd
D

i.1,,

,tü
.,t F+"

I l i s r - c s L r l t s ¡ r ' c s h o r lrhnc. b c . r ' r l ¡ s h i s i d c r r h c t i . l rr h . r ti r n r r d c h i ¡ r l r x r l i

v o t r n q c r ' ( l n (hl c n e c c l o s c r i n ¡ s c t o h i s y o u l t q c r r r i f . : )l .l t c r ci s r l r - r l l ¡ ¡ i ci t
¡ r o r c r r c n t i n r l r c c o r ¡ t o u¡lr f h i s l i c c .l h e l i p r r s L r c r ioo1nt l r c j o r v l i t h r l t cr r L r r
nrcntr¡iono1-thcnl¡l.u ¡r'c.rrlcfiltitclv1t.ttl.r svncrgisric cllcrrt:(lontl)incd\ illr
thc pcliolbit.rlrror'li.ltc tlocs kxrli I5 or-20 r'crr¡si'oLrrr!¡cr'.

\o¡icc .rlro l¡orvthc risurrllr¡nrl lilltetit¡n¡lh dclieiclltini.:r'iororbit.rlIint rr....

hLriltou¡ bv micnrlhtgrulting.A vcrv tlit'licLrlt 'l
trsk h¡s bccr .¡ccomplishcrl:hc
c r r 4 r h r h r r l n r i c . r p p c u rh - n¡ su lcrcc c nc l i l t i n r t c d( s c c . r l r of i g . l 0 5 3 ¡ l t t l r l l c . t c
r.onrprniinu -lhc.lcfLrrl
d i s c L r s s ifoi ln r l r ¡ c r ¡ r t h i st ( r p i c ) . c v l l u ¡ t i r ¡ to 1h i s1 , . ,
rllrrsln wils ()nl\ possi[¡]cbr'¡,-1,-linq ¡hc lrtcr'.rlc.rnrltirl sLrs¡rcnsir>n 1ogirc ¡ r'(r
trc¡l \ c c l ( ) rl ( ) f h e s L r f p ( ) 1s 1t s r c r rot f h i s l o t l c r c r c l i t J s .
394 Co¡rbnredApp¡oachcsan.l SFúgisric l'rocedu¡es

Complementary Procedure 4i Latetú Canthal Suspension

A lax lorvc¡ lid and/or scleral slxtw or lateral droop is an cxtteltelv common
problem in anyone over ap;e50. This rvaslbmerl,v a comnol complicatiou af'
ter skin-rescctionblepharoplastyand aftcr a transble¡rheroplasty miclfcce/cheek
lift. lt aiso may be prcsclt from birth, and is oftcn causeclbv subcli¡ical or full-
trlorvn nalar hypopl¡si:r. Latc¡irl canthal suspensi(xrJthc tcchnique rve usc fcrr
lateral canthopcx,v,is orre solution to thcse problems.

FrG.r0-43

AesthelicProblems
FacLadispfoponion I maar hypopLásiá Mcrofaigrallnglo malararea,
anda¡i6ro y)
(lransv€rs€ly
Rosuhanl ¡arcw' Iongiacé
Feslllanrdroopngol lal€racanlhus
androunding ol laleralower
Darkc rclesund€reyes:shadows
andhyperplgneñlation
SurgicalPlañ
zygomalic
árch,andi'rferoforbtai ¡im
Upp€rblspharoplasly w th láleracanlhal
Laserresurfacng to reduc€darkness
oj ihe peaorbtalskin
Mlcrolalgrallng lolearlroughand
 T h r S r n c , g \( ¡ 1 \ l u l t i i n o dt..' ,l . i . , 1l \ j u \ c , , . , L i { rh, :, r L i r gk , \ l l T ( ) g . L h ( . 395

Tfrc l<cvtr¡ unrlcrstlndin¡¡ancltrc:ltin!ithis plticnt is t() pcrccilc :rnddiagnr>sc

nof jlrst l \\'ell( chcek Lrone,but thc ¡rrcsenccol p.rnhlpo¡rlesirol lhc m.ll.rr
aonrl)ll]\:
l. Htlnplosi.n( tltt itt.litirr arb¡tLtlri .t (lrig. 10,13, (i), rercrling thc
. l ' . , ' r ', ' t r I u t l , , l ' . . r r r .¡i r ' r r L h r " '
. A slight cro¡rhthrlmicr|¡rcrrrncc
. loof slr|porl lirr-thc lxvcr lirl rnd globc
2. Hr,¡nplotin n.l'tltL: zt¡al¡it;¿ (iit.liiloi)lart¡0 0.1'LbtltrLti trl oi hiLtrl rii]t.
. l{evcilin!:sh.rpctrl'rhc globc on thc l.rtcrillvic\\'
. l,icn nr(¡-ci¡rp<;rf.rnt,rcsrrltintin .rnc\lrcnrclv lorv position firr thc
l¡tcr¡l c¡nth¡l tcnd(¡r, \\hich irr tur'rrrcsrlts in ir nrirrl<ctl t|rrvrrrv.rrd
shnt ofthc c1'clitls ( F i g . l0 43,,4). In ¡ nr¡r-nrrl ( h u c ¡ s i ¡ nn r i u o r
\ \ ( ) n r x n l,h c l l t c | l l c ¡ n t h u ss h o u l db c l L r o L r2t t o 3 n r n r ¡ b r ¡ c L h c
n r c d i l l c . r r f h u s I. r r r h i s c . r s ct,h c p . l l i c n t ' sl ¡ t c r I l c ¡ n l h u si s I h D o s l
4 nrn¡ 1¡¡:l¿¡r,lris nrcdi¡lciurlhus.lhis(lisl.lncc,irr ¡ddiliorr r() his L)f{^\'
'l
l)t()sisirrr(l rr sli!:lrt fl-t)lrtirlL)()ssirrg, gi!cs hinr rr pcctrli.rrl<xrk. his
sonrcrvh¡tstr¡¡u.c¡ppc¡ril¡cc is firr'thcrcrrh¡rrccdbt thc firllorring.
3. Hrlallü;d rl llr[ :.Vatulrtit d7-.r¡\ \vhich is dctccLcrl ¡s u¡rran'u¿ssc¡l
t h c s l i L r l ¡l t c r ¡ l l y . r t h c l c r c lo l t h c i n l . : r i o tl ¡ 1 ¡ i t ¡ ll i n r .r h c r c i t s h o L r i t l
1 r ( ) f r r r . rl )l lcyt h c w i ( l c s (t c o r r r p i r u f ci t h l i i g s .I 0 2 0 . ( 1 , . r ¡ r dl 0 2 - 1 , , 4 ) .
1. Hlp0!lo!¡n tl tltt tralnr ttttúrttt..; llr.rt is, thc .r)lcli()nr('sl prrrjcctirrn
rrl'rhcclrccliLronc.

F I ( i . I 0 - . 1 3 .c ( r ) t !

-¡{ +
396 Lu¡1b,,!¡ Aprror r L sr , d S \ r c g , \ u . n o . L ¡ r r ! s

FIG. 10-43, cont'd

()n thc lcfi chcck, thc n ar cnincncc m¡kcs onlv l tiny 2 mn clcvetitxr irLrovc
thc fl¡ttcnccl lcft sidc of thc ircc; try microfet graliing thc prolilc ofthc chcck
is brought to morc nor¡n¡l (thlt is, plcming) proporlions.This rcc¡uircdl
conrplcte Ltild out ofthc infLrio¡ orl¡ital rin ¿¡cl i¡cleccl the \r'hole zygonx
(rn ar complcx) by micnrfit grafiing.

Thc rcsult of building out thc zygom¡tic :r¡ch ud thc illusion of rcbuilcling
thc floor of the orbit and l:ltcral orbit¿l rirn is shorvn. The latcral ernthus has
-1his
l¡cen e]e¡,atedto a neü normal lelel. \\,asacconplished 6y lateral canthal
 The SID€rgyofMultimodal Fácial Rciuvcnation: Putting It All Togcthe.

The ¡esult of building out t¡e inferior olbital rim ¿nd malar eminence is
shown. These proccdurcs wcrc accomplishedusing only fat. C¡aniofacial su¡-
gery bony orbital surgcr¡ and bone grafs wcrc not performed. This is truly
structural fat grafting! Although I (T.L.R III) had my training in c¡¿niofacial
surgery, I bclieve in using a simplcr techniquc when it is this effective (and
much lessinvasivewith fewer complications), The qucstion surgeonsshould
askthemsclvesis: Is a preciscbooy rcconstruction required or doesthe paticnt
just need to look normall

Thc final pieccsofthe plan wcre: minimal endob¡ow üft with debulking ofthe
co¡¡ugator to take awaythe continuous ftowning or critical appearance,upper
blcpharoplasty,and lascr resurfacingto decreascthc darkncssof thc periorbital
skin.

In the results for this patient, it is cvidcnt that thc 6¡al rcsult is greater than
thc sum of its parts (that is, the rcsults arc syncrgistic). He has ransitioncd
(üthout cranioorbital surgcry) from what he rccognizcd as a "wcird appcar-
ance" to a normal, wcn attractivc, one. This changeploüd€d a hugc increasc
in his sclf-confidencc

Laarol Co*tbal Suspentiofi Concep,

Latcralcanthalsuspension is a smallproccdurct¡at canhavea grcatcffect.It
canalsobc advantageous whcnworkiagon a laxlowcr lid, in cascsofovc¡zear-
ousskin resectionduring lowcr blepharoplasty,or in lasingthe lower lid.

This techniqucmcetssevcralimportant critcria:it is quick (about I5 minutes

for both eycs);oncethc surgconis familiarwitl the anatom¡ it is simple;it rs
donc through the cxistingircisioo for uppc blepharoplasty; andit is dcpcnd-
ablc,safc,andcffectivc,Wehave¡cver hada complicationwith it, exccptslight
asymmctrycarlyin my cxperience,

I (T.L.R. III) lea¡ncdtlis proccdurcfrom jclks about 12 ycarsago. He has

now modfied his tcchniqucslighd¡ andcallsit the lateral rctinocalareantho-
plett!, bvt I stitl ñnd thc original tcchniqueto be safeand cffectivcin my
hands.The lateralpalpcbralartcry is an importantl¿ndmark.This vcsselpass-
esdirectly through thc lateralcanthusarea,and could be cncounteredat any
time. An elcctrocauteryunit andfltre forcepsshouldbe readilyavailable.
398 (i)Dbi¡rcd Approrches¡nd Srnergisri.Pr,.cdurc!

Lateral Cantbal SuspensionTechnique

Thc incisionusedfbr an upperblepharoplastyis fineto usefbr lateralcanth¡l
sr,rspcnsion. is not pllnncd,makea 2 cm incisionin tlrc
Ifupperblcpharoplasty
latcralupperlid fbld and cxtcndit about 4 to 6 nm late¡rl to the canthusill il
nolnr¡l skin line slantingslightlyuprvarrl.

l)isscctio¡ris carricdthrough and unclcrthc orbiculadsoculi, and thc lowcr

h¡lf of the incisionis clcvatcdrvitl'rskiu hooks.Tlre orbicularisoculi ¡¡rcl tltc
loosc¡reol¡r tissucarc ficcd fror¡ thc latcr¡l otbital rim.

FIC. l0-44

Thc right upper cyclid is sccn t'rom ¡tnvc. Thc orbicr.rl¡risoculi hrrsltc¡
o¡rcncclpirr:rllelto its fibcrs.Scissors
orc in positior to strun thc latcr¡l c¿ntl't¡l
-Ihc
tcnclo¡. undcr thc cut lowcr cdgc of
lcft doubleskin hr¡<¡kis lc¡'rositioned
thc orbicularismusclcso thxt it str'¡clcllcs thc cornc¡ ofthe eyc. Elcvltion on
this hook puts tensionotl thc lirtcm¡ciurthaltcndoD,which can [':cfirtrnclby
strunlning acrossthe soft tissucwith l lrlunt tip sucl¡asStcvcnstcltoto¡]y scrs-
'l
sors,sinril¡r to pluckinga b:rnjostring. his tenclo| is usr.rally tough and tc¡di
nor.rs,[-rutmav bc rvis¡r¡,.A thin bur tough ll,verof firscialics just nredialto thc
pcriostcul. Tllis fascianust bc ¡ricrccdbcfil'c the lcteralca¡¡tl¡altc¡rdonc¡n bc
sccn.Wc open this fasciab¡'sprmdiugStclcnstcnotornyscissors nlcdiirlto thc
latcmlc¡nthal tendon.
 Th( Sróc.$ of¡lulinnod¡l F¡ci¡l Reju\rnarion:Pufting li All l¡gcthcr 399

FIG. lo-44, coDr'd

Thc probc is insertedunclcr thc l¡tcr'¡l canthaltcndon. Oncc thc tirscii¡rs

opcrrccl,the lltercl ¡-ralpctrrll¡rtcry lrr¡)¡bc anyrvhcrca¡ouncitlrc tct'tclott,s<r
clissccfio¡ris blunt,splcadirrg¡
u,iththc tcnotonryscissors. Thc tcnd(n is ig¡in
by strumming,ancla scgmcntirbout4 mm kttrgcxtcndingclowtrtr,-
icicntiliccl
onto Whitnrll'stul¡crclcis idcntificd(Whitn¡ll'stutrcrclcis
wirrclits inscrtior-r
ir lump oftl'rickcnedperiostcom3 mm insidethe orbit). Thc tcnclonis ¡¡rls¡rccl
u'ith line-tootbcclfbrccpsrs fir bclow tllc orbital rim aspossiblc¡¡rd cnutcr-
izcclrvith thc llovic machinc(to prcvcntan rr¡plclsrnt surpriscfro¡rrthc lrid-
clcn¡xlpctrlnl lrtcrv).

FIG. lO-44, cont'd

Thc litcr¡l c¡nth¡l tendon is c¡uterizctl ¡¡rd tÍ¡¡sected. Its origin at Whitnlll's
tubcrclc 3 nm inside the ort¡ital ri¡r is dottcd rvith blue. The later¡l carrth¡r
tcnclou is graduall,r'transectedbct\\'cco thc fbrccps and the tendon insertio¡r,
inside the ort-rit,wltching firr blccding. As soon ¡s it is tr¡u-
ls lorv as ¡-rossible
scctcd,c¡r'ly h onc's cxpcrienccit is hclpfirlto mark both stumpsof the tcn-
-fhc
clou rvith ¡ tin,v dot of methylcnc bluc. firlccps grip on the stul¡p of thc
tcncl<¡l¡¡¡ustnot be ¡eleased (it is cliflicultto reloc¿teit among all thc lcljaccnt
whitc structurcs;hencethe tinv drop of Dlcthyleneblue).
400 conrb¡red Approlches¡n.l syDc,gisti.lrcccduf cs

'fhe
stump of tbe tendon is pullcd in an uprvard (cranial) direction and trac
tion is placed o[ the tendoo superiorly. The rvholc corner of the e-r'eshould
movc with it. If this cloes not happen, complctc transaction of the tendo¡r
must bc col]firmed. The tendon is ¡bout 3 ¡n¡D in dianctcr, expLainingu'hy
the 2.5x surgical loupes are so helpful. Ifthe co¡ncr ofthe cye still does ¡rot
move ¡fier confirming tcrrdofl traffaction, the ¡eason is onc o¡ morc fasci¡l
banclsradiating do¡'¡ fiom the tendo¡ to the itferio¡ orbitill rim si¡nilar to
spokcs of a lvhecl. Mrile pulling on the tendoD strmp, the sol-t tissue belorv
thc lbrccps is strunmecl, ¡ncl strands can bc fllt. Each band is lightly c:ruter-
izccl and cut with tenotol¡y scissors;at this poillt, the rcleise of the c¡nthus
c:rn l¡c fllt.

FIG. l0-44, cont'd

In Fig. I0-44, D, thc blackprobcwith a silvcrti¡'ris seenjustinsidcanclbclow

thc ldteralorbitnlrim; rlrc secondblLrcdot (abovethe probc)showsthc frxr-
tio¡1poi¡rtabout4 nrm abovethc origin:rlinscrtir¡roll Whit¡all'stubcrclc.I¡r
Fig. l0-44, E, firrccpsdcnonstrite the thick condensationof pcriostcunrat
the lnter¡l orbit¡l fim. Thc orbital stunp ofthe lateralcanth¡l tcndon is dottcd
with n sterilemarkirg pcn, as is thc ort¡ital rim just laterrl !o tlut stump. A
point on the orbitr,rlri¡n is rnarkcdabout 4 nm highel th¡rr thc first ma¡k.
Thcrc is alwaysa distinctcondensation oD rcdurrdxrrtperiosteLLm ¡t thc l¡tcr:rl
olbital rim, which Tcssicrsaidis "strong enoughto lift thc hcedoffthe table."
lfthere is extren¡elid laxity or thc origiüalsiteof the tendonw¡s too low (lcss
tharr2 mm atrovethe medialcanthus),thc upperdot may h:rveto bc ó o¡ cvcr
8 ¡r¡r abovethe levelofthe stumpofits originaliosertion.cAUTION: Ary clc
vetion greaterthan 4 nrm may resultir en Oric¡tal appearancel ¡t le¡st tcrn
¡rorarily;thc paticrt needsto be aw¿reofthis and must agreepreoper¿rtivel,v
 'lhc
S\ nerq\ ,,1 II!lrinul.rl I¡.irl llii!\c¡.trioo: I\rtins h -\]l TogLdrcl 40t

A 6gulc-oficightsrrrrrc.lockccl,shoLrltlbe ¡rasscdtlrlough thc rcnd()nstllmp

in rhc firrcc¡s. lhc sccr¡lclthrorv is p.rsscrl throrrgh thc tenclonirt 90 clegrccs
to thc lirst. .lnd lockcrlro obtri¡r nrr\im:rl purch¡sc(m the tcnd(n. ([ use4 0
l icron. trSS -\o. 305fi on ¡ % circlc cutting 1.3mm P l3 rlccdle.) Bcfiuc
locliitrg thc suturc, thc surgconslr()uldlook insiclclhe co.rcr r)l-the clc t()
rnill(ccctt¡in thc bluc srrtllrehls not trirnsgrcssc,rl
thc conjLlnctiv¡.

t-t(i. I¡) +.t,c.,,td

Fig. l0 ++, l, shorrsthc (ntir.tl .ontcr)rs rcflcclcd n)cdiirlh..rr'.¡vfiont rhc

l¡tcr¡l r¡1¡it¡l rim, rnd thc ncccilcis P¡sscclli()rn.i ntnt insitlc thc ¡r¡.llit.If
rhc llcrirrr¡l gl¡nd is cr)c()(¡otcrc(1.
ir citrtsintplvirc pushccltilthcr LrlckLr¡rinrr
rhc ()fbit, ()Lr¡{)f rhc rr'.rv.lhc rrccrllcnru\t cnfcr thc Icril)stcunr.3 nlnr insirlc
thc ()ft)il. A nc\\'. r))()rcs!rpcri()rinsct'ti()¡fi¡-¡llc tcnrlon is l.cing crc¡tccl.
rrnclit nrt¡srirrisclir)rr .¡ nrnr irrsi(lctltc ortrit. sinril.rrr() \\¡hiln.rll'stubcrclc.
(tALtt()\r If the sutr.rrcinstcrd onl! cnq.¡ttcsthc
l)cfi()\lcll¡t ilt rhc lc\'clofthc
dru, thc llcrrl c¡nlhLrs¡ncl l¡tcr'¡l colncrs ol thc litl till rlivcrgc tiom thc
{krLrc,lc.tinq l slr.lrrga[x)king spxcclrc¡rvcenthc lirls¡url rhc ck)l¡c.'Ihcrc
iórc thc nccrllcnrustcrtcr lhc pcfirlr,lc!¡or 3 nrnr insidctirc rinr..rnri frug rhc
tronc ¡s it lc¡r'csthc or'LritourtthloL¡F,h lhe conLlcnsilli()n ofthc ¡rcriostcunrol-
thc l¡tcrirl ()¡titill nr. c¡rcfgin!,.rslir'l:rtcnlll oLrlsi¡cthc orbit.rs ¡rossibl.,
jLrstinfÜirxtothcup¡rcrr1ot.Thcsrrspcnding40licr'orrsLrtulccntcrsthcpcri
ostcunr.3lnm i¡rsirlc¡hc (nl)it. As nrLr(hl)eúostcunris grthcrcd .rs¡0ssiblcb.-
tbrc critinq lltcrirl ¡o thc o¡titll Iint.
402 (innbined Appr)achcsand S!¡c€ntic lrocedures

FIG. l0'44, cont'd

In Fig. t0-44, G, the dircction is rcvcrscclirncl thc ncccllc is ¡rasscclfionr tl'tc

outsicicin, protcctingthc ortritirlcontcntswith drc back ofthc firrce¡rs.Thc
pcriostcLr¡'nis cntcrcd ¡bovc thc uppcr d()t ¡t'tcl scvctrl millinlctcrs l¡tcril to
-fl,c
thc orbit.ll rinr. surgconscripcsalollg thc bonc with thc necdlc ¡nd cxit
:rsfirr down i¡'rsiclcthc olbit rs ¡-xrssiblcto gct as big l bitc ofthc pct iostcL¡rrirs
possiblc.In Fig. l0-44, H, thc sutLrrcis ticclls tightly as¡'rt)ssiblc, irnd rlrc c.r¡1-
thlls cirn bc sccn snug up insiclcthc o|bit, lrut 2 to 3 rrrr highcr (it clocsnot
firllow l :l ). Thc krot is now insiclcthc olbit, lrclow rhc ¡'in],whcrc it c¡nnot
bc sccn or filt. Thc skin is ckrsct{xs an}rothcr blcphirr4rhst¡ Thc lowcr licl rs
pullccl ttrrvnrvllcl; it should rcnrain nrr.rchhiglrcr irtrcl tightcr thiu prcopcra-
tivcl)r (tALr'ft()N:Bcc¡uscthis rc¡rairirttrchesthe tcnclonto pcriostcunr¡nd ts
not dlillccl ir'rto¡¡'rclsecurcdin thc bonc, it miry tcncl to fclix ovcr timc. Thrs
hls not bccn l problcm clinicirlly,but ifthcrc rl,crcsolncongoing or rcpcated
stl'csson thc c,vc(fi)l cx.rm¡rlc,ifthe ¡rrtictrt rubbccl l¡is or hcr cycs cornpul-
sivch,).wc would rcconmcnd ¡ morc clcli¡'titive¿tt¡cllmcnt into bonc.
 I r.\\f.r!\ ( f \ l L ' l t " i r \ l . r l l : r . i r l l t . r ! \ ( ¡ . r f ( n r : I ' r t r ¡ n ¡ :I l . \ l l l i , g . ' h c r -103

Conrplclnentaly Procedurc 5: SrrbnasalLi¡r Lift

It is rrot Lrrrcr¡rnrorllirl thc uppcl liP to lcngthc¡rsith rr¡ic.It {ircs ¡n u¡r.r¡
tr'.rc¡i\ ¡rt,.lis jusrone rrorc rlis¡rltion llonr idcll p|r4rorti<rns
c .rl)|c.1r.1ucc th.rr
dctr'¡etslionl .rttrirctivc¡rcss.

t : t ( i .l o , t 5

AeslheticProbleñs SurgicalPlan
M ó r ó i a l g r a l r . a1 0l e a rr o L g h
L¡ck ol niá ar proleclon M crolag l r ¡ l l ' i o l ! r d u q ' n e . l a l o .o l l r i c d l r e é k

M n o r r p o s l c l o f o l r o ws
M crolag l r a l l n rl o ra u ¡ r ¡ r e ¡ l a l oo
nl 1 ¡ ec h .
¡ r d a l c a c r r f o l c h a s o ! ¡ c r c r sn !
Shorlv.rl ca heghl of m¡xl bc v c r lc a l r e0 h l o f m ¡ n d r b l e

'l
h c l o r r gL r ¡ p c r - l iiP s . ¡ l s os c c r o
r c c ¡ s i ¡ l ll l r 'i r rr o r r r r u epr c r 4 r l cs. L t ( h. r sr l t i s . 3 ó
v c ¡ t o | r . 1r r o n r ¡ n . A l t h r r r r g ht h i s , l c g l c c o f l i P l c n ! , t h ¡ l r n c n r i g , l r nt ( ) t t ) c
c n o r r r l h1 o n r o l i \ ' . r tcc( ) f r c c l i ( ntrh, i s \ \ ( ) r r r J ¡nl s o r r ¡ r t c d m ( r ' c I l l l r r c \ s( ) l h f f
r r p p c rl i ¡ . . \ l t l r o L r ulhl ) c u 1 r | c rl i | \ c f r ) r i l i r ¡rrl r o r ri s u \ u r l l r ¡ b ( ) r ¡ l7 O ' l ri ') 8 { ) 9 i
o l t h c L r r r c rl i p i r ) ¡ t t f . r ( t i \ el o n r c n , i n ( l L ¡ ( l i r r\ qu p c r r ( x l e l \ ,o e e ¡ s i o n ¡ l l ivt
c . r n b c r r ¡ r o l 0 0 l l l h c \ i , , c ( ) f ¡ h c I n v c r l i p . l h c : c f . i t i ( ) s \ ¡ r \d f . ü l i x t i c ' . rt1r i1l l\l
cfhnic bir(l(qr()r¡rr(1, ¡rr(l cren \ithirr il sl)crificcllrrricqf()lrp.bul in rlnrost r
g r - o u pi s . r n u f p e f l i l ) l c s st h ¡ ¡ r o n c r h i r t lt h c \ i r c . l r r J h c i ¡ ¡ h o t l thc lrlcr'1i¡
cr¡rsiclclctiitle¡1.
+o4 ConnriDed Approaches úd Sync¡g¡ti. Ptr)ce.lures

FIG. r0 45, cont'd

Thc sulgicd plan consistcdofrcmoving a block of sL<in

and subcutaneous
tis-
sue,.s outlincd in J¿llrD

Thc upperincisioll¡nusthug thc bascofthe nostrils¿ndcolumella precisely;

if
cloncin thiswa¡ it is an impcrccptiblc incision.Thc ¡ratientis showl l0 clays
postoperatively.Somc ccchymosisfiom the nicrofat glafting to thc tcirr
trough rrrd malararcasis still sccnthrough her makeup.

goalis prinarilyto shortena loug lip, rhe tissueis cxciscd¡nd

If thc clcsired
thc lorvcrecigcoftlrc incisio¡r firt 2 to 3 mm,justabovcthe lo-
is unclc¡minecl
cl ofthe nusclc.

lf morc shorvof vc¡¡rrilionis llso dcsirecl, the skincx¡ be undcrmircdplo-

grcssivclyt'irthcr, unfiLrlingthe vernilion. llcsults ca¡ bc chcckcdwith a cou-
ple ofsuturesbeforccortinuing. Ifstill nrorefüll¡tessis clesired,micÍofit gÍatr-
ing canalsobc pcrfbrncd to thc uppcr lip assoon ¿rsthe incisiol is suturcd.

I'he vcrticalwiclthofthc strip ofski¡1exciseddependson how conservarivc thc

surgconand paticnt wish to be. cAulto^-: There is ¡o possiblenay to rcvcrsc
tl¡is oper¿tionif too much is rcnovcd, so bc conscfvlttive.It is easyto excise
more later or cvcr thc ncxt d¡),,if lecessarl'.Generall¡ removing25a/o of ff,c
ve¡ticrl hcight ofthc skin ofthe lip lvill give a conselvativeshortcnirg ofthc
lip andunfurlilg ofthc vermilio¡r. The ch¿¡1ge is not quite l:1.
 The SynersyofMulrimodal FacialRejuvenatio¡: Ptrtting k AILToBether 405

The incisionin Fig. 10-45, D, will elevateonly the cenual two rhirds ofthe
lip. If more fullness is also needed laterall¡ and the patient already has a na-
solabial crease,the incision can be extended into t}¡e nasolabialcrease,taking
out a Bu¡¡ow'striangleasin Fig. l0-50, B.

Ifmore emphasis ofcupid's bow is desi¡ed,the lower incisionis modifiedasin

Fig. 10-50, B, üdening the strip of skin excisedpreciselyabovetlte cupid's
bow peaks.The resultcanbe fairly dramatic(seeFig. 10-50, C).

¡IG. 10-45,cont'd

The lip lift is ody onc ofthe subtleprocedu¡esthat contributessynergistically

to facia.lrejuvenation. In this case,microfat grafting was done to givc more
projectionand verticalheight to the chir. Microfat graftingwasalsodone to
the late¡al chin notch, tear trough, and malar areas,Minor liposuctioning was
performedon the jowls. But the resultis more elegantthan we might expect
(admittedl¡ complementedby the makcup,hairstyle,and jewelry.)No lipo-
suctionwasdone on tie anteriorneck;it is simplyhidden by the mo¡e appro-
priate increasedverticalheiáht of the anteriormandible,createdby microfat
grafting.
406 Combined App,o¿chesrnd Synergisricl¡oc€du¡ei

FIG. l0-!tó

This ó9-year-oldman had a long upper lip and both lipswere extremelythin.
He wasawarethat the combinationoflong upperlip and extremelythin ver-
milion (evenon sideview) was unattractiveand m¿dehim look edentulous.
Eve¡ with his mouth opeo (Fig. 10-4ó, C), his upperteeth could ¡rot be seen.

Balancewasrestoredby subnasallip lift and augmentationby microfat graft-

ing, givinga much more appealing,youngerappearance. No other procedures
wereperformed.In the lateralpostoperative view,his mouth is openalmostto
dre samedegreeas in the preoperativephoto, but now his fuller lips yield a
much mo¡e natural profile. We perficrmedan extended(into the nasolabial
fold) subnasallip Iift and simultaneousaugmentationby microfat grafting.
The resultslook surprising.lymore attractivethan one rnight haveanticipated.
tq
ü
 Thr srn.¡gr ol \Iuhinro.l.rlF.,.i.¡lRct¡¡c.¡rk,r: h,trirg ft.\ll [os(ihc. 4O7

ReirrvenatingDiffi cult Regions

_fo
devclop :r surgic:Llplirn fbr paticnts l'ho rcqucst tircill rcjuvcnatior,, it is
bcst to .rnelvzcthc ficc bl r'cgions.Thc fbllovin¡l cascsrvercchosenLTec¡rrse
c¡ch onc illustr¡tcsorrr ilpl)roilchto onc p:uriculirrlvcjithcultrcgion in thc rni
Iicrrof corn¡rrchcnsivcfircill rcjulcnirriorr.

Forehead
IjIG. ¡0.47

A6sthotlcProbleñs SurglcalPlan
Doeploreheadl¡nescaus6d by chronic Endob¡ow rill,ñico,at g¡alllñg(wnh pick¡e
fontalismusc6 aclivilylo ové¡come lork V dsseclor)loloreheadin€sand
browplosisandupperlidredundañcy

S c e r as h o wa n dr o u n d i nogl l a l € r al d Laleralcánlhals!spenson
f ransconJunctival
lowerblepharopasly
W¡nki'rgoi owerlds andmaar áreá Lase¡resurlacing periorblaland
malárar€as
Prolo!ñdma¡a¡soll I ssueplos¡s Microlalgralling.someareas , 2

Liposuclion andjowls
ol medialcheeks

Faqalañdceryical
laxily

l'his nr¡n's loosc jorlls ¡¡lcl ncck irle inncrli¡tcly evident,lrut if n'c srart svs-
tcnr¡ticirllv,tionr top to trottom, uc cen idcntiñ lll thc chlllcngcs $'ithour
nrissingxllr. Hc tlcnro¡rstr¿tcs (.rrnonqnlinv othcr thitrgs)onc ¡rroirlcnrnor
discusscd: crtr¡ordir)irrilralecpcrcisesc¡uscdlTl erccssfiont¡lis musclc¡ctir'-
itv, rvhichin tlu rr rcs!¡ltstionl blockagcof his supcriorvisurrlficlclbv his uppcr'
licls utl Lrrorl ptosis. l his requircti nrx onll cntloblxv lifi ,rrrtl[¡lcplrirropl:¡sn,
but ekr "picklc fórk" (V-clisscctor') clisscction
and microlirtgrrliing to thc nrrrl-
tiplc dccp tirlchcrrcl lines.
408 Conrb¡rcd Appro¡ches and Srncrgisric |f)ccdu..s

He.rlso hacl prof<rur-tdmalar h,v¡roplasia:rnclptosis ofthe sofi tissucs.Llecause

of the need fbr rhinoplast,v¡nd ¡ flce liti, thcsc rvcrc accomPlishedin trvo
stages,and we took advantagc of the second proccdute to do stpPlemcntal
nicrolirt grafiing to thc arcasofgreatest sofi tissuc dcficicnct'.

FIG. 10-47, cont'd

'l'he
results¡rc shotn-
. L)eepfirrehcrd crcescsgo[e
. Bro\\,and licl ptosis irnprovcct
. Sunkcn chccksnorv have reason:rtrlcprojcction, except prccriisting tratl
matic scirrat midchcck
. Faci¡l ¡nd ccn'ic:rl lexit)' improved
. Improved chill projcctio[ and contour pcrnitted patient to s]r¡vc hrs
goaree
 flrc Svn€¡gvof¡,lnkiDod¡l F¡ci¡l Rcjuycnarion:
I,u¡rúrgft A logcthcl 409

Periorbital Area

FIG. t0-48

Aesthet¡cProblems

Four-lid
b epha¡optasty
hrabrowand ld skinis crépeya¡dheaviry Lase.rcsor,aclng
ol p€riorbilaar€a

M crofalgraft¡gtogtábottar furows,tea¡
Üo!gn.andro augment lhecheekbones
a n di l l l h e a l e r a l c h inno t c h

MACSIfI

'Ihc
¡esthcticprotrlcnrsofthis 46,ycarold woltr r werc nrosrlvin the pc¡i-
orbitirl lrca, anclnrde hcr lool<tircd, or possitrlvcvcn dcpressed(rvhichshc
wasnot). She |equir.cdalnost evcry¡rer.iorbitirl tcchnic¡Lrc
rvc had: cnclob¡ow
lift, blephlroplastl',microfirt graftir.rgro dcep rcrr troughs ¡nd m¿l¡r f¡cr¡l
g¡oo\¡cs,cheekeugnlentxtio¡,and lascrrcsurlicing not onlVfor her \\,rinkLJ,
but to oblircratehcr ntalarbags (fcstoons).The ¡csult is a sparkling,livclv,
morc yo thnll looi<.Her lurks rou, ntatchher pcrsonaiiry
410 ( inrbnrcd App.oa(hcs¡¡d St'rcrgisricProced!.cs

Mi dface/Cbeehs//awlin e

FIG. lO-49

AeslhellcProblema SurglcalPlan
MlcrclalgÉltinglo lsarlrcughandlo empha-

ol modialch€€ksañdjowls
Liposuction
grálting
Microlal lo marioned€ linss
Teñbleeyolidbagsándw.iñkles Four-r
d kánsconjuncrivalb €pharoplasry
Lassrresuñac ng of perorbilaar€a

Fullacé Litl,iposuclonot ¡6ck,p atysma

This S5-vcar<rldrvoDl¡rris ¡n cxcclrtivcwho had just rcccivcd¡ major jot)

promoti(m ¡nd rvontcda f'rcsh,youngcr lrxrk. Her mai¡ c(tlrplaint wxs, "M,v
cycsanclncckobviouslynccdhclp."Thclc wasnuch ptosisin tlrccheek,lntl
thc jlrvlirc rvasllnost totally obscurcdby jowis ald submludibuht lht, t'ulclc
rvorscby microgenia. Hcr comprehensivc pl¡n w¡s implc¡¡cntcdin onc st¡gc.
Shc is norv cnjof ing lifi more th¡n cvcr.Shc hasalsojust bccn proposedtbr
¡rlothcr iob ad\,¡ncemcnt.
 Thc St,nergyof Mulrnno.lalFaci¿lRcjúvcnattr,n:
Ptrttingk All Togerher 4ll

Periot'al Area

FrG.lo-50

AesthatlcProblems SurqlcalPlan
grafiingro holowupperlid€,
Microlát tsaf
Upperlidsareveryholowandsunk€n lroughandho¡lows ol midcho€k
Holowñ€ss ol midcho€ks a rnosir€voas
lh€ olllne ol lho skul
Veryedery lookto mouthronguppérlp, Feluvenationol ñouih a.€a
d6epnasoabialfolds, sxtr€mely dsep grallinglo nasolabial
¡\4icrolai lolds,I nes
moulhfuga6,lhñlips,corne¡sol moulh áound moulhandlaleralchin noichés
lLrr¡down niornar¡on6l€in6s Lipaugménlal¡on by micolalgralting
Noichn9 ol mandibular marginal aleral Shapeol subnasallip lilt 6€l/ow)cañseec-
livelyomphasizs cupds bowp6aksánd
gv€ morevormiio¡show,in addilonto
crealinga moreyoulhlushorrerupper ip

This ó9 ycar-oldwor¡m's f'acelooked gaunt and harshon prcscntatiou.She

saiclthat he¡ nouth looked like that of ¡n 8O-year-old.Hcr pli,urincludeda
fcw spccirl thi¡lgs to deal with thc gaurrürcss,including microfht graftiflg
Q¡reen)to inftabtow/uppcr lids, te¡r trough, and nidcheeks).Hcr pcrioral
areawis cvcn worsebecauseof varioussulrkelrarcasa¡ound her mouth. ex
tremelydecp rugacand wrinkles,thin lips, and a long upper lip. Her plan in
cludedan cxtcndcdllp lift (yellow)specrally dcsigncdto emphasizethe cupid's
borv,and nicrofát grr,rftingfbr extrafullless.The deepestñlrrolvs¡l,e¡efilled
by microfátgraftingand carcñrluseofthe "picklelbrk" V dissecto¡.The later-
al chin notchcsu,crcfilled,and the u,holeperioralaestheticunit ¡¡'assmoothed
by laserrcsurñcing.Her entireplan wasundcrtakenin one sitting.The result
is a softcr,youngerlook. The softeningctlcct of the microfirtgrafting to her
upperlidslnñ'ebrow is quite interesting.
4t2 combincd Apprce.herend Svncreisric
Proccdurcs

TheEmpbthalmie Iaob (KBugEyes")

FrG,l0-51

The causesoftruc cxophthalmosarccomplcx,but rcsultin an appcarance sim-

il¡r to this woma¡r'sfbr difltrent rc¡sons.In a patientwith truc cxophthalmos
causedby hypcrthyroidism,thc orbit was origirrallynormal. Exophthalros
carrsesh,vpcrtrophl'ol most of thc orbital structurcs,cvcn thc cxtr¡ocuiar
r¡usclcs.Thc result is too nuch volunrefbr a ¡rorm¡l-sizcdorbit. Trcatment
has inclrrdcclorbitotonlics, outfiacturing or rcmo\,¡ngthc rncdial, inf!ri<-'r,
and/or latcralorbital s,alls,or cvcn crlniofircirlsurgcrl,iu sclcctcdcases.Thrs
scer¡sIikc ¡ bit much when thcrc is no risk to visi¡¡r or othcr ¡rrotrlcmsassocr-
atedwith cxophtlr.llrrros and lry¡rcrthyr'oiclisur.

FIG. l0-52

Thc rp¡lcirrirnccof cxophthirl¡rosor pseudcx-

oplrthalmos (bug-cycd ippcarance)is flot rarc
ltnd cx¡ Icxdto il st¡rtling, unpleasantappcar-
-fhc
irnce. causcis primarilymalarhypoplasia
and sh¡lk¡w<¡rbits.
 l l r ( . \ , _ - A , r l \ 1 . , 1 i , , " ¿l ,: r ' i ' l ] I q . , \ (' , , { l ' r r u r ÉI \ l n ! f . l ( r 4t3

FIG.l0 53

Ao3th6tlc PÍobl€mg SurqlcalPlán

aug-6y6dapp6aranc6ol6xophrhÁlmos:Micrcrarg€ninglobuildouh€inlerior
uDDerlldreuaciion,sclsralshow o|bitaliimandmala¡€min€nc€
Hypoplaslaof nferiororbllalrim Lareralcánrhalsusp€ns oñ
FrownIn€sgivolheappoarance gralilngro lrownin6s
olan angry lMicrolat

Low6r l¡dbags and wfinkles Blspharop ol péri-

aslyilaserresurlaciñg

Toarlrolghilid-ch€€kj'jncllon
is dislincl; grali¡g io leartrcugh,malarlacial
Microtat
vsrllcáheghioflow€rlldsisloo longand groovs
asymmerfcal
Uñuslalydeepandlongmaroneltegroovos fi¡icrolar graftinglo marionoil€groovos
Th¡nlips Lipsaugménlgd by m¡orolaigrált
Fac¡állaxrty Faceand¡eck lifl

Thc 57-yc¡r-olduonrrn in Fig. l0-51 ¡¡rd Fig. l0-53 hircl¡ h¡rshor critic¡l
look on prcscntation. lhis plticnt ¡rrcscntedfirr fici¡l rejuvcn:rtion.Shcposcd
problc!'nsthat Nere prcliousl)'uns()h'irble b¡, trirditionrl aestlrcticfhciil procc
clures.For tl'rispatienr,l los er blcphirroplasrysrrulclonh, r'nirkchcr cxophrhirl
nric ppcirrrnce worscj bccaLrse by rcmoving fit thc shapc<lf rhc protrucling
rould globc woulcl[-tconrcnore visiblc.

1'hemosr impomanrlxrt of her ¡rlan\\'xsextcnsivcmicrofit graftingto bui[.1

out thc clcficienti¡firior orbit¡l rim and malir cr11i[cnce, \\,lrichcoulclthcn
conce:rl thc shillo\\'olbits.E<¡ually,importantwis thc rrpwirclrc¡rositioning of
hcr lorvcr lid ¡r¡¡gin to clinin¡te thc sclcr¡l show ald staringiplicarance;\\,c
r.rscde latc¡alcanthalsuspcnsidrto lchiele this ¡¡oll. Thc crccssivefat, rlhich
bulged irlcgularlr',rvls rcmovedbv blcpharo¡rl.rsn. Nlicroflt l1r:rftirigN¡s tir
pcretl up to thc ta$il pl¿tc to givc il nr()rcn¡tnrill look.
4r1 ( (i¡rl.iri(l lff 1 f . r \ t r . ( 1S r r . - i t r 1 . l ' r ( r r ¡ L r ( \

Thc finr1 pcliorbitll frc.llnrcnt\\'¡tsl:Lscr-rcsLrrlircing to rc,:ltrcclr-inl'lcs.rlr.l

i1.rrl<circlcs,¡nrl m¡Lc thc Jid chcck jLrncrioninrpclecptiblc.\lhcnocr r¡nc
.rrc.ris s() uniltll.r.ti\c (.r¡tl so rlil'licLrlt
1()c()r.cctl.it ir ll\'.trs \\isc to dctcl
nrinc \\ h.rl oLhcrpr(rcc(Jurcs coulcl ¡tld ¡Ltr:Lctircnesst() thc ticc. In this..lst.
.r ticc ¡nL1nccli litt wcfc pclfirrrrctl .lnd thc pc.uli¡f ric¡r'cssionsr.rtli.rting,
rlxr n tiorrr lrcr nroLrthryclc Iillc.1in.

It,

\ {

\
$ \,
$
'¡

\
\,7
\

\
'l'hc (rl c\(4)hflr.rlrl)r.
lcsult is ¡ nrLrcltr¡r¡rc l)lc.ls¡nrticc rrithoLrtr h.rrsh:'l.rrc
lppcilrilncc.Shc lr¡r lirllcr chcclisiionr thc LrLriltl oul ol hcl intiriol o¡bit¡l
r-inrs.Thc jorls ¡r'c ¡l¡scnt iurd thc j.lrlinc is clisp. lhc p()sl()l)cf.llivc liltcr¡l
lior (Fig. l0 53, ( i l . n r o r ct h ¡ n I v c r r - ¡ t i c rs t r r r : c r s! ,h ( ^ \ sc s s c t l t i i r lrll\( )l o s s
of thc f.rt glrfting irrd gtxr,:1 tl.rinLcu.rucc of thc r.:orl¡orrr.
 The Syn.rsyof Mnkimodil rJ¡ci¿lRc¡,vcnattr',: t\r¡ri¡g tr All Tolicttrer 415

Comprehensive Multimodal Facial Reiuvenation

Frc. 10-54

Aeslhel¡cProblems SurqicalPlan
Gauñtlook:sunken uppérlds, i6artrough, Microtál g¡atring
to sunkentids rsárl¡oush,
holowmidchooks, de6pnasoabiattotds, matararea,hotowotmidctr€€knaso-
m¡n¡mallacal subcuiansous I ss!6 abiaiotds
Lower¡dbagsañdwri¡kes,crowsleet Laserfesudacing lo periorbitatar€a
Foor id tra¡sconjuñcltva btepharop
asty
Facialandcérycallaxty wiihp alysmá F![ lacetiitwilhanlériorandpostoror

Las€rf6surlac
ñg ol roralace

'fhis
57-yclr'-oldwo¡rtn prcsentedwirh ¡ g¡r¡ntingptttern rs rvcll ¡s irll othe¡.
'visualsignsof aging,inclucling
splotchypigmentation anclsol:rrclamagc. Hcr
rcjuvenation rcquircclall the traditiou¡l¡Trocedurcs,u,ith:rnentphasis oll mi-
crotit graftirg to hide the skulflikc ap¡rc:rrance
ofhcr t'ircc.The resulris x nirr-
llr¡l look. Shcl<xrkshetlthier alcl pcrbapsa bit youngcr.
4t6 C,'nrbinedApr¡,i(h$rnd S\'nersisticI'rGedurcs

FrG,r.0-55

Aesthotlc
P.oblems Surglc8lPlan

Upperlidssunl(sn(gaunl) Micrclalgraltinglo hollowuppor6y6lids,

Soltlissu€ol ch€skslidesdown|ev€aling low6r6y6ll&,l6arlrough,malarar6a,
ñldchs6kholow,nÁÉo abláliolds,
Atrcphyanddesc€itolmldch6€klal mák- nolchosot mandlbuafmargnat alofal
ingcheeksappeargaunlandbony
Lid{h€okjunclioñis dislinclañdlow€rlid Microlalgr¿llinglo lear lreughañd malár

Ey€ldbág8 Fo'ir-lidl€nsconl'incllválbl6pharoplasly
Lp wdnkl€s,
vermllion
lhl¡ Lipaugñénlallon by r¡icrclalgrallingiás6r
fÉsulaclng of pslofala€a
Minimál l¡po8uctlon
ol iowls
Fulllac€lif w¡lhanterior andposi€rior
Loos€n€cksklnandplaiysma bands
Oarkpigmenialion
andwrnkl€sol the ol pe o.bila áñd
Lás€rr€sldácing
p6 oú tál€ndpe¡ioraar€as

This S9-year-oldwoman'sonly daughterwas gctting marricd in a ¡'ear.Hcr

appearance in youth is shorvnin Fig. l0-3, and hcr multiplesignsofaging rn.f
gauntingare idcntifiedin Fig. I0 4. Hcr trcatmentrccluiredrl'nost everyt<xrl
t¡l our armatTlcntanum,
 'l
h c S ! r e r g !( r ' i v l t l r l n ¡ i . r l l : i c i i l l ( e j u v c n r t ( nl1' (: r r r i r gI r A l l l h g c r h L r

F l C . I O - 5 5 ,c o n t ' d

-l-hc
clcar,snr<xrth,Iitcr.rllvlxrtrct ski¡r¡.lrlPcclrxcr hcr ti¡ll chccks.tndcrislr
jlslinc convcv¡ gcrru¡rrc¡nd nirtur¿lbcirtrtvth.ll Eivcsn() lrints()fits sur!{icxl
()riqin.

I¡lG. lO-55,.onfd

A g e2 0 Ago60

AlthoLrghthis p.ticnt does not l(x)k 20 aglin, hcr firciitlpropoftions,firllncss,

look thirn in hcr agc
:rnd hcalthv ippcaraurcc:rrc nruch closcrt() hcr 1'orrthfLrl
59 prcopcriltivcphoto.
4f8 (lo¡rbnredAfp¡¡rhcs úd S\¡(gisii. ltu.cdurrs

To accorr¡rlishthc n()st nitur:r11 harrronioL¡s rejuvcnirtion,especi.rll,v in cliffi

cult cascslikc these,thc sulgconshould mistei not o¡)h,rllc "Bi!i Four" (ficc
lifi, blcphar'<4rlasn',
bnxv lift,lnd rhinoplirsu'), but ils() tllc fi\'c s\'ncrgisticpro
cedurcs (nicrofirt gr.rfiing, lltserresurflcing, jucliciousficial liposucti(11,l¡tcrel
cxnthalsuspc|lsionl¡ncl subnas¡llip lifi). Whcú thcsc proccdu¡csirlc irp¡rlicd
optim¡ll)', thcy pfoducc tnrc syllcrg,v:sc\ic111 livc) ol cvcn th¡ ee ¡rroccclrrrcscln
licl<l closcto ir "pcrf¡ct 10."

I] II]I,IO(]ItAPHY
B¡ylislll, L{nrgJA, Gforh Mj. l usconjunctirirl l¡¡rvr:rcvclid blclrharr4rl.rsn. lcchniclLrc
¡nd conr|lic.rtiors. Ophrl).rlnr(,log\' 94,r1027- 1032, 1989.
(incnr¡n SR. l¡.i¡l ¡rlimcol¡li¡nr $ith strL¡ctnl frt grifii¡9. (llin ll¡st Srrrg3.3:567
577,2006.
(itcln¡n SI{. ljrcirl rcconr(nrfing $,iih lip¡)stflrcttrrc. (llin l'lirslSufg24r3,17-367. 1997.
(irlcn¡n Slt. L(nrg-tcrnrsLrrfi\'¡loffir trinspl¡nts:(inrr'()l1cddcmr¡ns¡¡ri<¡rs. Acstl¡ct-
ic l'lirr SL¡rg19421'12511995.
(lolcnrxnSlt. Strucnrr¡lF¡r (;rrfiinS. St L(n¡is:Qu¡lin' ñlctlic,rll\rblishing,2(X),t,pp
295 297 .
(itcnr¡n SIt Stnrrnrrrl i¡r gfirlting:,\4(r'cthiurI pc¡rlr¡nct fillcr.I'hsr llc((nrsrfSurg
1 8 8 ( 3S L r p p l ) : S 1S0182 0 ,2 0 0 6 .
( i ) l c n r i ns l l . S t r u c t u r rl l l r , f r l i s :l h c r d c ¡ l f i l l c r ¡ ( l l i u l ' l x s r S L r $ 2 8 : l 1I 1l 9 . 2 { J 0 1 .
lirgicnS. ;\rlvrncciirclurcn.rtircuppcl blc¡h.rr'(Dl.rs¡v: Flrrhrurciog.rcsthcti.s (f lhc L¡trtrcf
pcri('rt)ilr.l'lrst R.c(n r, Surg I I0:271t291,2002.
Fitz|r¡firk RF;.(ioldn)xnNlli.S¡lur Nltl, c¡ .rl.l\rlscdcrrbon<lioritlcl¡scf rcsurlicing(f-
phor(J.rgcd fici¡l ski1r. Afeh l)cfnrirn)l132:395'402.199ó.
(;l¡t l)M. Jcll$(;W. Jclls l-ll],ct rl. Ll\()loti{n('l thc ldtcnl crrnthr4rhs$: 'ltchnrclLrcs
rntl
indicJlions.l'hs¡ Rcc(nrstr Surg 100:1.3961405, 1997.
Ilcsrcr'l R, (ixlncr ItA, (llinr(nrl)M, Nrhri F. ct ¡1.A. l.:\()lütirrr(l-tcchnie¡uc rf thc cli-
rccr trrnsblcpharopl.rs$, .rppro.rchfbl rhc corrcLri(nr(f k)\\'cr lid rnd orirlfirei.rlrging:
Mr\inrizing rcstllrsrrr(l nriniorizinB c(nnl)ljc¡tious io ¡ 5.\,crtrcxpcricncc.l'hsr ltc-
c(nrsí Slrfli 105:393406, 1999.
,¡cobs(nrA. ltrdiogrrphie(lcl)l)trlonrctrr: Ir¡rn ll¡sicsro Vidcoim.rging. (lhi(-rf,o.IL:
Quinrcsscorc ltblishing, | 995, pp I I 7 | 19.
lclks (;\\¡, (llrr liu, tclks l:8, ct ¡1. Thc iri¡rn,r rctin.r(:ol.rfl.ucr¡l c.rr)th{4)l¡st\':A nc$
tcch|iquc.l'hsr Rcc(nrsrr Surg I00:1262 1270,1997.
L¡mbÍJr V. F.rtinjcctionfir thc:rgingmirltircc. OpcrTcch I)listSr¡fg512,l9UU.
Litrlc ,!V. lhrcc diurc¡si()uilrcju\'cDrti(rr()f dre nlidl¡cc: VrlLrmctricrcsculptLrrc bv
rl¡l.rr inrb cation.Pl¡st l{c.onrt¡Surg 105r267-285, 2(XX),
Ilcndcls(nrl]( 1.Iltrz.rrlirAI{. Acl.rl¡sWP i'. Surgicalanrtornv ofthc n chcckrnd mrl¡r
mounds.l'1.lstRcconsrrSorg I l0:885 896,2002.
fcss¡ IFl, l)csvigncLD, Lxnrt)ros VS, cr ¡1.(lh.n1ges in oculif gk)be-toorl)itLrl fim posl
ti(D $,irhrgc: Implirxii(nrsfbf.rcsthclict)lcph¡¡opl¡stv ofdlc lowerc\clids.Acsthet-
ic fl¡st SLrg 1999 231337-342.1999.
l{()bcrtsTL. lhc ultr¡pulscd(lO. hser: An inDoft¡Dt ncw r(xl in rhe ¡cs¡h{ticpl:rstii
surgc(n'sirnl¡ment¡riun1.lrcscntr(lrt lhc,\nrurl ¡lccring ol rhc ¡\tncri.rnSo.icN
for Arsthctic I'lasti. SLrrgt r\'. S¡n li rocisc(', trlxrch I 99 5 .
 ThcSyncrgy
ofMultimod¿lFáci¿l
Rcjuv€nation:
Putti¡gIt All Togcrher 419

Roberts TL, E¡lis LB. Ia pu¡suit of optirnal rciuvc¡¡tiod of thc forchced: Endoscopic
brow üft with 6imultaneousca¡bon dioÉde lascr resurñciag. Plast Reconst¡ Surg
I01:1075-r084,I99ó.
Robcrts TL, lrycinfcld AB, Bruacr TW, ct al. 'Universal" and etbnic idcab of bcautifi¡l
buttock¡ a¡e ba¡t obtaincd by autologousmicro frt grafting ¡nd üposuction, Clin
PlastSulg 33r37I-394,2006.
Tor¡nardB Vc¡paclc-4, Mo$trcy S, et ¡1,Minimal acccsscnnial suspcnsionliftr A modi-
ñ€d S-Iift. Pl¡st Rccorist¡S\rA LO9\2074-2O86,2002.
Tonnard PL, Vc¡peclcAM. Thc MACS-üft: Short-ScafRhytidcctomy,St Loui6: Qualiry
Medical Publi¡hing, 2004.
ádc BM, Jclk¡ GW, cds. Su¡gicalAnatomy ofthc Orbir. Ncw Yorh R¡vco Prcss,1985,
pp2r.65.
 Index

A A¡trntr nñlll¡ry hv¡nDl¡u Br¡v pt.5is

r\.{h(ti..nrih\i\ mirnlir Fnliúr8 ¡n¡, 37.1 ñlA(:s liti ¡n¡. l9l
¡¡¡uni. b¡\ú or'f¡trry\mrnhpcniion ¡nd, rrnicrl hrishr (l !ff.r li¡ I¡r. dLB¡.. ol rcñ¡(trrl lÍi hv li\cnF\\ ,n ,276
2(7,261,266 r ( ! r y I n n r r f r . nn r , 3 5 1 3 Bru.. (innr(ll\iN. l3rl.l39
.r¡nhn¡nr8 ¡ \ 1 4 ( : sl i l i \ r n ¡ r . D l p a n l l i l r r\.triorpl¡rsn d¡!\.¡t2.¡').1,202 'Bnscrcs._412,¡l.r
¡¡, 3 I 2, 3 I ó, 320. .r2,r.32ó A(, r. S¡ctrc¡|.I 86 l!úrching tis$., nr¡.rgin8, Il A( :S liii \|lrt
¡ilii.rhn.s¡'ljtriil!¡l¡.r¡¡.1óll.l72 *A{nrn¡c ipr{¡nü¡.c..1¡Drc¡(t. r.¡¡i s.¡rl¡..|Íi¡.19óI97.¡93.
¡t\(rs lÍi \ltfl {¡rli..liirtr¡,200. rnnlilli(^\ lili.2t6 2o4
202 ^u8nrrnhrn lnr¡s. )¡r,380,38¡
A{^(rslilit.ehtrnN.r.l18,l32,l¡4. ('r'r1slc('r'i$\.¡70 ¡73 & f n ¡ ( k s ,i u a t r l c n ¡ . f x , n l ¡ n t r l r s h l i n l s
l ¡ 6 . l 3 l l , 1 , 1 ¡ .I . 1 6 .1 5 0 .l i 4 , l 5 l l . (f l'r{|,ckr,38f) ,!r1,380
1 6 2 ,1 6 6 o l . h i f r r . ( ] r j n , ¡ rs n r c n r i ú n l f
| r n n i N D ( r i h r ¡ ¡ ( l i b u l ¡ rg L r ¡ dr , 1 7 4 . |fg.\',lrnrr,380 c
t76 , f L , r . n r l . h i nr ¡ e h , 3 ó 6 3 ó 9 ( i f t r r l . $ . h { f v c s i t r g¡.5 4 , 3 5 5 , 3 5 , )3. 6 2

2 2 ¡ 1 , 2 3 02,3 2 l ) l . r y s n rr r s f c n s n l,242 nrs|crirÍl

s x t r r s c . nr o l i i , r r i , ! c l i i i i n ¡ , ¡ 2 , 1 4 , 1 6 , A r r l . u o d f v N ¡ ¡ l l i 8 i n r Lr r , n l \ i r ¡ s , 2 4 4 (i¡rlxfc\f, Lf.f.rl,3e¡
2 0 , 2 4 , 2 6 , 2 r l ,3 0 , 3 4 , 3 ¡ 14, 0 24ó.251,25ó,257,2óll (inrh,)1ni*r'.l.r.rr .rirrrúh.397
\v(c n,trir it,troirli r,' M^(rs-Liti o¡ch. Au!)l,ig,n^ Iir srllii¡s. 3só O¡s. Lr¡ntlc\
r n . r . . h n ! ! . r , ! k l , 1 0 2 ,¡ 0 4 . 1 0 6 . ¡ ¡ ¡ ! t r n i . l ) ¡ : i ! f l l ¡ r v $ n i $ ^ r ' c n \ n r r¡ D ¡ ,
ll0 B 261.767

2¡16,lllll.290,292 tr¡n .nnl,2s| r .312 319

Asna l ¡ . r k ( r , l ) ¡ D i rl 2. l , l x 1 , l N 7 ¡ l ¡ ( S l Í i n x n { , ü l i . . l i , i . n ¡ ¡ ,2 ( X }
hn^\.2¡)8 ll.rl)((l nrur( l,n'Ix.l\l^( S hlr .nr¡. ¡91 203
rici¡|.ín¡c^r.nllnrg\nil)lcrh¡ngcjol: ltrl)c¡ sú( i'rtnrnrknn..l.l8ó ¡t¡(lsliri¡..hrnl¡r(¡nrl.¡18 I19.la2
3ai) 3-tó l]lfln,I lrfi!, 350 1,10
s ¡ t n r ü r A l l ¡ r L r ¡ , ' l ir " ( n ¡ n ¡ i r 8 f ¡ r . f r l l i , . ( r n ¡ r i l i l . r i l l c r|.t r n ¡ n c t r . n r i . i ¡ n i r n x t r ' s ¡ r r l i t c l i l i r n . l . 2 l 2 l2 3 2
¡frsni¡ FnlrnrS¡.3só 357 \lxtrrtcrrrcdicrlliccIili.ukl,12.13
ihr r¡trrnrn li,ú'crr (n, ¡38.:139 lllqrhüoch¡Lsn, l8¡1 \N.Dritir ipN,,¡.h r') MA(:s litr (,t'.rr
ri.(lr(fr!rc.¡ l¡¡u¡$nr,339 ¡41 !t,[r.24,36 ¡yc¡c!!nnt!$¡n¡,102 ll2
n,rn'rl. M^(ls lil' rcrhnúu. ¡¡(1, 1,1¡ l]lqrh,ú)flir! tcrlptril lili liy li\.i.r|.r\ rxl. zlt3 2e3
1.15 n ¡ \ c r i ú l r n v c rb l r t h r i { ) d $ r r ( r ¡ l ! ^ s n r c c t ¡ r rúi . ( l , N r t r ( h i ( s , ^ d , , R l
, n N r n r n i L ¡ r c ¡ .¡ r i c r n i ug r r t i i i r 8i ñ i , flnrh,2e6 l(!|ü'l{ir¡r j¡ ¡r¡(i¡lAcj j(i.
3 l l(ñcr.y.L ,l8 S L r B c fr\ i r c ( r r l l
l n l i l i , , i i l t u r l r l r l c sl i Í l r . i r i r r s c h r n g c s u p p c r , 2 4 , 3 , 13¡ 5l 0 ( i c r v i . i l l i s . i . rr.r N ¡ i r l i l , 2 3 8
r,3,1ó350 h ¡ l y . . n n n r f n gr r y ( f l , l i r r t l h . r l ] D o r . h ( l c $ i r i l l i r , r t r . r ( r n i .h s n , n t i l . r i ñ n ri l r
A L ' , l ) c . i r r, , n r s i c rrr.,n r ¡ Í r l l i i l ) y¡ r s . i r r i c r y ¡) rcjfvcn¡rnúsr¡l vin.l,190 N¡rn ¡n(i,251
rnd,282 h r , " i n . l ] ( f r l l t r n n rr ¡ ' r i n (rc 'r¡l liti.2,17
^r,rrit,$ sotid! nr Ár{ h.¡i¡ rú l)i.*ti. ¡nft Lir¡ uDrn xi¡ l ln f, i\ ) ( rcrlir.nrc¡riL .nrglc,1t1^(\ lili nl. l ¡ l
sur8crv,33ó, ¡80 ,ur.r¡n'i 6,si\ ¡f t)lr$nr natJrii,trr.n , (llcrks
ADryl.¡(.p¡rr l(¡k.r¡l, ¡17 251 152 .rrrnnr,rl23l)
r\N\aN. ¡r{hrnrih A.nhdiü ¡Dilv\n bnnr liri ¡tr¡,:98 r¡nr¡|.,362
r\Nro¡iir li,rn,n thrrsn.r nx¡.¡:nrr,237 ri.iil p¡¡\r i!¡, 1.13 nrrl!,3ó2
26e r i & h c r , l¡ D d . 3 3 0 r . ¡ ¡ t c n ¿ t n n r , n+.¡ r )
4tr.:rh.n¡ lurri¡l lc'k tri,I, I27. llll3 (:hin
b!trv lili r\1.3.ró d¡r\ i¡.'l li,nnhnl. 2i0 rushcr¡r¡(rr (,f
IIA(:s lili \hon+¡¡. ri.. lili rnü, I9.1 19ó fr.oNr¡rirc. ¡n¡,¡nic h.hiin ¡rhN!¡¡ .hnr inld¡trr ¡n(1,l8
s\{c.r¡ri. .r|troi.h n,IlA(iS lili opetu n*trcn\nnrrn(i,2il 2il b\ nn.'1n¡r!rnrri!r!. aóó
rna rú(hni{uc\ ¡¡.1. $0 8l InNic nrr.hnrc.l¡crrl ..nrhrl t. ,n ind. litfll$r su¡Q rn¡. I78
^nslr ¡99 ¡cgrc. ol rckxfinfl (l lir nr, 35$
g.i,ri¡l.i¡gnrcnÍtnnrof¡nglcor'irqtrnd, l]¡o\ \c¡k,¿ugnr.nhtnnlfingL.,fj,¡\inll,
374 hcisl)rotl337 370
o l j ¡ \ i r " J ¡ \ 1 ü r g l c( ) f Nsnn ol297 ( l h i nn n r [ n r , c h ] ni u s n r ( i r ¡ r n DN n h , l l l

¡$ ,!rl,372 i r y o u d n nlL¡ c c . 3 3 7 l¡r nr,3srJ

A n r c g o n i r l n ' t . hr. f g n r c n h t n ¡ ro l ¡ r g l c o f B,orvignrs.298 c l h n ¡ n i c or i . t r l . n i s o . u l i . o n r n d n t ¡r ¡r 1, 5
jÑvind,370 l¡owlili, 1r2,2tó,34ó3.r7,.111 C i g ¡ . . t t c\ ñ ( ) l i n s i n , s n r ¡ [ i n F
^ n t c r n t r r . r l l l r r i i n g l c .c l l ¡ . i o f r l ¡ r y r m r cn¡os.opi.,347 C n c l e sd, i r k . t r n d c r c v . sr s, i n g , x l . 3 4 r )
{s|cnsn¡¡ ,!r. 250 Ilr\(:s- liri :h r¡s.Í li¡c I'lr rn¡. 199

421
Chv, sNlplnrg ll-odr,plriir surgcr\ Diincüh nñn¡l)iJ nnd, ¡!r^( rs liti ¡cchrilLrc I¡.irl p¡lsv.tc¡tn.nt ofscqrclxcoi.2,13
Fi.iil proportions¡rd condú\. c¡1.
(;11Áu.c,
rItc¡ blcph¡rophs!a¡nd. k¡o\l.dg. ot.336 338
ro.rhning ltlA(lS lilr wi¡h rc¡por¡lllli hri.rl rc.oni(,unns.tr.hl 'c¡trc rrnD rersr,
Ldv.r ir¿ns.ontrn.ú¡l bl.phú)tnr$\ in¡, 33.1335

DnriDiznrg{drklcs Nn|, ¡¡10 s ú bS M r \ S\,i t h . c ¡ o ' i . 0 h f i n . i s i o r , . o n r p ' . h . n i y c ' ¡ n l r i n r ¡ l ¿ 1 . . 141158

(i,l¡ light fcr¡(or. tcm¡nll,ri bv ris.i¡
Pcxr¡nd.2l¡2
(i,ltDin\'cg0l¿r.]ntrulis. ¡ri.ft)tit gñ]iirg
i n ( t ,3 5 5 . 3 ó 2
(i¡nl)nr.rl ¡ppn,r.hcsin¡ \rncq¡ñt. prc.(
¡ r r c r , 2 3 5. 1 1 9
xutrni. Fs,s ofplinaD.r srst)crsn,rinrl,
( n ¡ b i r i r r r ¡ñ l A ( l S L i l i{ i t h r . n l ¡ , ' r L L i t i
\ynrfg\ 1,fn¡¡nn ¡l firlil rcjLn.nÍnnr
r¡(i.331.119
rc¡r¡rrl llll l1\ ñ\.lrtc\y r rl.l:71 :9.1
( i n ¡ b i r i r F M A ( l S L i l i$ n h ( r i 1 t ! Í i L L i t i r
n . M A ( i S l i l r ,ü n n t r i i i i l g\,' n h
t93 v.rüs li.i¡l rc..rttrri'rg,334 335
¡cnrlani¡lili trt lisri¡ttxv 1iJ,278 280 I t l A C Sl i l i s h o r s . r r 1 ¡ c . l i r ir i ¡ , 1 8 . 1 I l t T
l)og c¡¡s,slrct s.¡rlirc lili rtrd,72 nnrLtino¡¡1,svnrrStoll r.1 i\'l!liinx,J.rlr'r
Do\v¡Nx,¡ gi¿i,rtj!ic\. 138, t3t .ñl rejo!cr¡tnm. slncrg! ol'
l¡rwirg toursr. plis,. !!gc.l, rrsidcn.i, li.iiL $tu.h'rr, burl(lrns.nri.trf¡¡ gnhnrg
l)\"l p()th\li\is: rri l)ccp vcirrilron)t)asis Fiú rrxlnlÍr rór nnnl rrrr t¡rc Lili.215
lÁltllrir. fnlgo isistc¿ nrtrlti.c clev¡nnr
J o'ó\: Pi l¡r'ú\ l¡rri.r
Elrfrrii\. skir, poor,70 f , l J c , h . i r. c n 1 . ¡ r , 2 3 8
t t ¡ 1 t x r i ) | r ¡ c ú 12. 7 3
Liklollot)ir |,ftr\ llri, 3,17 r c n r ¡ r 0 l i i n ú k l ,2 . 1 12. 5 ó
lin¡o{ot)ir nc.k lili, 47 l:,s. if(\v, r.nr¡,iL Lili ¡\i rt ltfi¡nrl litr
L n ¡ o ¡ n c¡ . \ i . c , o ¡ . r ü ) l ] i r l ) r ^ r l i ¡ i i n d ,

(iñf .n,c,t¡ry p()..¡rr.\ llvc.sfr*snit E n n i c r ¡ ¡ s n i l n g t. l i . r o l l ) r . h r x l . 3 s 0

l i f i , i r ¡ f r G i n ( 1 ,¡ 5 0 4 l ¡ l.(lnr1n¡rfri r. lnrI onrcrs (lu,!rúy ncc(lc¡.t,n 0riüoliL gnlii|9. ¡57

in¡rotr)lr l)isi! ('11)Lfyi¡r s*tcn\nn,u , v o L r r n(. ' 1 g

l b r Ll i ¡ u ¡ ! ) r i t r n j c . r n t r r rx l . 2 5 2
\ 1 4 ( r s L i r ki . r n n t r L c¡ n ¡ , 1 2 2 l 2 N
i¡ú {rr lir. Liti.!ri, 72, 221)
\$r(Nri. ¡fIrr.l) !, ill^(lS llli ,,1)c
1 i \ . t . r h r q t r r sr \ i . l l ) l
r c n f ( n l j l i l ) \ l i r . r P . r vr n ¡ , 2 8 2
( i n n t ' ( h c n \ n L r r ( h i ¡ o ¡ r ñ . i i L r . ¡ N ' rr . !
(ir¡!r1r' rnr.'siris,l¡.i¡l fc.,trrrrrf ill¡ rxl.
( o ¡ r l ) ! 1 c r z d1 ) . r r . r ig . n . r f , r ' ( ( i l ¡ ( i ) .
| s d r sr ¡ l . 3 l t 9
( i r n ¡ 0 l l ¡ , N r g i z i r ) g\ i . $ , 1 0 4 .1 0 5
( i r n { ¡ n \ , i d c n h ! i , r l .k ¡ , \ v . ¡ g L , f , 3 ¡ 6
I t t c r r ) t ) r i r s ! i n i n Fr x l . 3 t l 9
s.n,,r¡( il ¡lr,3lll ¡82
l l r \ ( h c . r .( l ( ) . l , N u¡rn ¡ , 3 8|
l^(rs rkltr.rtrfini.1).\is 1)lrrLr1Nn,,
f.¡ri,rr inrl, z4ll 24e
l l v ) l n r h r l n ) lL ¡ , r , [ .4 l 2 - + 1 . 1
l i , l n n r l D r ¡ , k r . . . . n r s . \ o l ; , {l 2
l i l c n l l c l l M A ( l S l i r l ( ) i M ^ ( : S ) ,r r . 7 , 2 9 6 .
lirr (lr\nc$, gcncril rrLfhcsir ¡¡1. 19.1
liYcnli!r l,¡trv.rL i Lr||rr l,.l
¡ ü k r i r f l e rLn ¡ c r ,r g l n si n ( 1 ,3 1 0
. rili.J,35¡
{rs rrrk.n rtlltr LnlM¡,346
l:,,rnrcr)iñntrr, i)i(rli1 Brrliing r rl, 3i5
I:rr r.{.rrfr, r trtrc'bl(thi',)fli{y ¡rrl, ¡.lN
l . l : ñ 1i f I r r r I i n . I i r ¡ i r . . e f r L fr ü t r l . L ir g
l . s , ¡ t r r s ,L r s c ' \ . n t r3i N
. 1,.109
f i l ) f n g h r c s, [ i ] i. L , , r i r rr n J , 1 9 9
fi,ru\us. ¡crl)cti. ticiil\!g.r! r rl, 3¡.1
l r i g . r . \ \ i f . r 1n r d l i . c r l u \ , r i ( n lr| ^ M l l ) .
i t l r \ (r s l l i r n ¡ , l l ) l
lii,rc clcrrcnr¡r\l.lint¡ (l:l-lñl) rDr.r.h,

( i , r r ' i r 1 u . . l p l ¡ t y i n r ,. ¡ , ¡ r o r r l cl , s i s . l l r ( t r 1 ¡ ,t . ! u .,uA(ls lill rl. 123124.

f L r l l s n r ! \ f c n \ n n ,n n ¡ , 2 4 3 .\rhnrnr) oll lif 1Jl.¡m¡,s\u.nr ¡rl ln
(ifr.r¡erri.s, Art, rn¡ [.hnoL(,91 i', F¡!i,,1 risi,)rs,r|lfl s.ú li.c Litiral, s:l Firrpi¡i.k, lll.hitrl, 380
iUsl)ctiú sur!¡.rv ((iA f|ASl D*r Fnc c,r¡t)lcncnh l fü,(c¡r rcr. s\furgiirr
r ( ú h l n L , . h . r ¡ r r ( r i \ r i . s , f¡:¡ 7 l,n¡rcJurcs¡n{1.ili0
( i r . t t l i t t r ¡ i f l $ $ , 7 7 ,2 , 1 7 !ic! liri. 4. 3.17¡'lN.,ll8 Fo¡nr,ri i(.n. br.kcJ, f.{ofc'xrnc ¡'crr
( i r n \ r L i , , g , d i l f . ¡ h c , r c r i n ¡ . 1 . 1 51. 5 . 1 M^(is lil¡ \lntrr \!riv¡ NIA( S liri sL¡¡1 i n g r¡ n i , 2 0 0 . 2 0 4
(n,/l¿!ú1 dqr.¡srr,, 37s
(rl)(;r J1¿(inntntrriz¡d 1l1tc'r scncnntr rr.o¡¡rri.1\'lA(is Liri¡, l.rl l.!s
(i¡nn,ti.ir !rrgrf\,o ritorcnti.,33¿r rhtrt \.r't v.Shorl s.r'¡¡.c lili ¡rin!¡.r in. \ ith rgi18,.l39
( rf¡nnr trbihl sr fgcN, 397 útrr s.r' vcrti.rli rd. Sli.r \r¡. \.útr,,l ¡ri.¡tir grrti¡r8 rn¡, 357 35S
(ircr). L,Nc' ¡.¡n\..n¡rnúiv¡l bLcl)hrrcdNy rcúcn¡rnn ot..107.10¡l
lio¡r¡Lis itra.Lc, \crkncs o1,28¡
(rr\v r t¡ú \vritrki.s,339 l:n$¡rB ofsknr,fhrnol lJc.l\ rr¡,3ri0
(irni\ü¡\,s'l]|n\¡l liplik¡ ..r05 t ¡ t r \ n l i n c r ,n r i . f f ¡ r g r ¡ t ¡ i r gr n d , 3 5 7 3 5 8
0n¡crdMdnrgy*nnc ¡,Jgcs ol, i39 3,1ó
D i¡ri.¡n)pl¡t1lnd ligr¡rcÑ .l: 2,1.12,tó,
dr vin.r,i con¡ú.i,336 .ldsrccoir.r)4r¡nr ollil i¡,35¡l r5l, 25ó.157,2ó8
l)1'k.¡.lcs ur¡cf crcs.¡gi¡B rdrl,3,10 r' ¡c¡tril ni.rot¡¡ gntting ¡ir¡ rug¡rcil
I)tcr ycin ¡n.mb(ri\ (D\T ) fr.ph!li{ir.
g c r t h l a r c f h c r i ¡ ¡ f ( 1 .1 9 4 li.i¡l di\fiorrornn is rds.o r¡r ¡e$hctir li
l)chisrcnce,l¿v¡&r, $lcn u|1)c' li¡ ¿n'1. ürlnúgc.t,333 G
j,r2 343, ¡.15 Fr.i¡l lx\cf rcuTi.ing. roh¡,386 389 (irlcr. rcmn.r,p.ni.ul tis.i¡ rnrl, 273
Dctc6omllzúon, J,1¡.uk .¡scr ¿nd, I ó8 F ¡ . i ¡ ll , t o s , . ¡ o r , 3 8 9 3 9 3 , . 1 1 8
l)cprcrrnnr.,¿,? l¡, !,r,r, 375 F¡.il rcilc, rcn]p.¡xl t)ai.h or',prrLyss or', nniih.d tcn\iorilLilb i f,3l0 3ll
D c ! . r , r l ) r s . r , 3 1 i l3 8 3 \lntrr rc¡ tc¡rponlliii bv.330
 rD(rcf 423

(;.rh(rn1g¡hcnonr(non. 187, le2

(;.¡'rrir8 p¡r. ,n ¡gnrF,¡38.33e, ¡J: I n ' ¡ t . n n . . h i I . . n r { n r r n r . n si nú h . l r l.¡rúralh.o¡nrs, (o'rnrnriIS¡¡¡( s.l,r'r\üh
rhrús.\ trnn¡u.n), ¡-¡ 1.3-16 ¡Lnltxtrrllix ,n . ¡llt
{rnkcn u¡i¡i(r Inl c¡u\c,l l)r..¡{3 rrl.'((nrc¡r,1. s\i. ,( i( ,'¡r¡r(r.h ro ¡ -t.i¡l (trl[rl !D¡. /rS({nrir t,trúr (f. |r
( i h l ) ( ü r r n r o \ \ . ¡ . s ¡ . ú , f ¡ c k , ¡ n r n r , ¡ tt ¡ r Il;\(:s liri ¡'txlilfr r(!hnnlü.\ ¡ ( ' s ' . ro r . : 9 5
Lrr¡ l f¡l|!hr.rl rrcrr, l.n.nl .rrh.rl \tr.
(ilnlnlA tl.nr\, rr,úún¡i. l)¡rn (t f l,!\\nr.r
rj(n\nnr¡n(1.¡tr7
nrsl)tr\nnri!(1.2.13 rtrn ri(ul¡r. qrh S¡li\s(l¡\LLrnnr \1rh. 1..{cnl rc¡i'rr(rl¡r. rh,'tn.Nr, ¡97
(ilu(. li¡rh. skitr.l¡Áu.( ¡nd. l9e
l . ¡ r ü r l S ¡ l Á s r . ! ¡ r \ . . 1 6 .I l 0
(ntrn¡l ¡!ts|!. ¡¡gnr.rd nn! f .nrSlc,,l irs n ! ú { , r t ¡ ( . l i l i ¡ r l . 1 6 . { 9 .i 3 . i 9 úr(h(lnrBd¡r\j¡.r '(\(dntrr. I I lt.2le
rc¡'tanrl h¡nlnic. ¡lr\(:S lili rcLh¡(u( Lr.'il \\c(f f h.r(rncn(Í. ¡l. l+¡. ¡,tl
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