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Vanity surgery academy face-lift training course, Seoul, Korea

Suspension of the retaining ligaments and platysma in facelift; from “fake-lift” to “facelift”

Keizo Fukuta, M.D.
Verite Clinic, Tokyo Japan


The sagging of the facial soft tissue is more evident in the central zone of the face where the tissue is more mobile for facial expression.

The facelift procedure must correct the aging deformity of the central zone. The skin and SMAS are anchored to the skeleton or fascia by the retaining ligaments.

The facelift procedure which pulls either skin or SMAS in the preauricular region can not mobilize the central facial skin if the retaining ligaments are intact because the ligaments block the traction power being transmitted medially.

Those surgical procedures only stretch the skin in front of the ear with little, if any, correction in the central face.

They are not a true facelift, they can be called “fake-lift (false lift)”. This lecture presents the anatomical consideration and technical logics to achieve true “facelift”

The role of facelift procedure in facial rejuvenation (Figure 01,02)

Different areas of the face show different signs of aging.

Up to now, surgeons have developed many procedures to treat each area; for example, forehead lift for the forehead, upper blepharoplasty for upper eyelid, lower blepharoplasty for lower eyelid, facelift for lateral cheek and neck.

Therefore, when we evaluate the surgical outcome of facelift procedure, we must focus on the correction of the contour in the lateral lower part of the face, particularly on the jowl, marionette line and nasolabial fold.

This lecture presents the technique of facelift which uses the release and suspension of retaining retaining ligaments and SMAS.

Localization and function of the retaining ligaments (figure 03, 04)

The skin and subcutaneous fat of the face adhere to the underlying deep structure such as the parotid gland, temporalis muscle, masseteric muscle and facial skeleton.

The strength of the adherence is not uniform over the face.

The retaining ligaments which are present in limited areas anchor the skin to the deep tissue.

Those ligaments originate from the deep structure, penetrate the SMAS and insert into the dermis with many ramifications.

Therefore, the ligaments provide with strong adhesion between the skin and SMAS and also between SMAS and deep structure.

The parotid cutaneous ligaments connect the preauricular skin to the parotid fascia along the anterior margin of the parotid glad.

The zygomatic ligaments adhere to the zygomatic body from just lateral to the zygomatic major muscle, extending medially across the zygoma and maxilla in relation to the origin of the zygomatic minor muscle and levator labii superioris muscle.

The masseteric ligaments are the vertical septum like structure which conjoins with the masseteric fascia at the anterior border of the masseter muscle and attaches to the mandibular ramus and body along the anterior margin of the masseter muscle.

The mandibular ligament anchors to the anterior third of the mandibular body. The orbital retaining ligament adheres to the inferior orbital rim.

A role of the retaining ligaments in aging face (figure 04, 05)

The skin and subcutaneous fat, as aging, lose the firmness and become difficult to maintain their shape resisting against the gravity.

In the upright position, the skin and fat tend to sag down vertically in an older person.

The adherence of the skin to the underlying structure is not uniform in strength.

The retaining ligaments attach the skin to the facial skeleton or fascia.

The skin over those ligaments shows minimal displacement under the influence of gravitation.

The skin of the neighboring area, which has less firm adhesion to the deep tissues, shows greater ptosis.

Therefore, the areas on top of the retaining ligaments develop depressions or grooves in aging face.

The neighboring areas which lack in the anchoring of the retaining ligaments create bulges.

The jowl deformity is the bulge along the mandibular border, which develops due to sagging of the soft tissue between the masseteric ligament and mandibular ligament.

The marionette line overlies the mandibular ligament.

The malar pauch is a bulge due to ptosis of the soft tissue between the orbital retaining ligament and zygomatic ligament.

The midcheek groove overlies the zygomatic ligaments Thus, the face develops multiple grooves (concavities) and bulges (convexities) on the surface with aging.

A role of the retaining ligament on facelift (figure 06 - 09)

The purpose of the facelift procedure is to pull up the sagging skin and subcutaneous fat, convert a facial contour with bulges and grooves into a smooth one.

The aging sign of the face is more prominent in the central portion of the face than in the lateral part.

The facelift is a procedure which excises the skin in front of the ear; thereby the surgery can stretch the facial skin in the lateral part with tension.

The traction of facelift is less efficient in the central part of the face.

The use of SMAS allows the traction of more anterior tissue than the preauricular region.

However, the SMAS is strongly anchored to the underlying tissue by the retaining ligaments, which restrain the traction power at the lateral margin of the SMAS.

The elevation of the SMAS can not mobilize the sagging skin in the medial face without release of the restraining effect of the retaining ligaments.

It is important to release the zygomatic ligament and masseteric ligament in order to correct the jowl, marionette line and nasolabial fold.

Facelift procedure with release and suspension of the retaining ligaments and SMAS (figure 10-19)

The incision is placed along the temporal hair line, in the preauricular are along the anterior margin of the helix, posterior margin of the tragus (.retrotragus incision) and ear lobe, in the retroauricular groove and along the posterior hairline.

The subcutaneous dissection is carried out until the lateral margin of the platysma and muscular portion of the SMAS are identified.

After further dissecting medially above the SMAS and platysma by another 1cm, the incision is made along the lateral margin of the SMAS and platysma.

The dissection is then performed under the SMAS and platysma.

The subSMAS dissection continues until the zygomatic ligaments and masseteric ligaments are completely released.

The zygomatic ligaments are ligated in the superficial side (close to the SMAS) before it is cut.

The ligation sutures are later used to suspend the zygomatic ligament in the lifted position.

If the tightening of the lower eyelid is planed, dissection is carried out under the orbicularis oculi muscle over the zygomatic body and inferior orbital rim.

The lateral margin of the orbicularis oculi muscle is suspended to the deep temporalis fascia if planned. The vector of the lift is perpendicular to the nasolabial fold.

The most medial zygomatic ligament is suspended to the periosteum of the zygomatic body using the ligation suture. The masseteric ligaments, if they are ligated with suture before cutting, are sutured to the SMAS over the parotid near the parotid cutaneous ligaments.

The zygomatic ligaments in more lateral poision are then suspended to over the zu\ygomatic arch or tempral fascia. The lateral margin of the SMAS are pulled supero-laterally and sutured to the SMAS in front of the ear.

The lateral margin of the platysma is anchored to the mastoid fascia. At this point, the skin of the medial face is mobilized and dents or grooves may be evident on the skin surface along the attachment of the cuff of SMAS and platysma to the skin.

The excess skin is trimmed along the incision and closed under the tension which is just enough to smooth out the dents or grooves.

Clinical experiences

In the past, I used the small SMAS flap with minimal sub SMAS release limited over the parotid, lateral SMAS ectomy and lateral SMAS plication.

None of these procedure released the medial zygomatic ligaments or masseteric ligaments.

The review of the patients who underwent those procedures showed early(1 to 3 months postoperative) recurrence of the jowl deformity. (figure 20-26)

The review of the patients who underwent the current operation with release and suspension of the retaining ligaments and SMAS showed less or no recurrence of jowl deformity. (figure 27-33)

Short scar face lift(figure 34-39)

Short scar techinique is currently used. A short incision is made in the hair baring skin in the temporal region.

The incision continues in the preauricular area and corners along the ear lobe. The skin is terminated in retroauricular groove.

A short horizontal insicion is placed along the sideburn to avoid surepior displacement of the sideburn and temporal hairline.

The dissection plain and extent of the dissection is the same as the above mentioned procedure. Gather is made along the preauricular incision to deal with dog ear. The gather becomes unobvious in 3 months



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