A study of the long-term effect of malar fat repositioning in face lift surgery: short-term success but long-term failure

In 1990, the author reported on a series of 403 cases of deep plane face lifts, the first published technique describing the repositioning of the cheek fat, known as malar fat, in face lift surgery. This study examines the long-term results of 20 of the original series in an attempt to determine what areas of the rejuvenated face (specifically, the malar fat) showed long-term improvement. The results were judged by comparing the preoperative and long-term postoperative views in a half-and-half same-side hemiface photograph. The anatomy of the jawline (superficial musculoaponeurotic system [SMAS]), the nasolabial fold (malar fat), and the periorbital diameter were evaluated. The results confirmed that repositioning of the SMAS remained for longer than improvement in the nasolabial fold and that the vertical diameter of the periorbit did not change at all. The early results of malar fat repositioning shown at 1 to 2 years were successful, but the long-term results showed failure of the early improvement, manifested by recurrence of the nasolabial folds. There was, however, continuation of the improved results of the forehead lift and SMAS maneuvers of the original procedure. The conclusion is that only a direct excision will produce a permanent correction of the aging nasolabial fold.     

Rhytidectomy and the nasolabial fold.

I describe a technical modification in the Skoog face lift procedure that releases the deep attachments of the SMAS to the muscles of facial expression for maximal mobility of the medial cheek yet elevates the cheek flap as a composite of skin, subcutaneous tissue, and SMAS to enhance skin perfusion. My results with the procedure in 100 patients are analyzed by using functional zones of the nasolabial fold corresponding to underlying musculature and a simple grading system based on preoperative and postoperative photographs. Marked improvement in the nasolabial fold was noted in over 80 percent of patients by 6 and 12 months postoperatively. This effect seemed to last up to 4 years.     

The SMAS and the nasolabial fold.

In a series of histologic sections and clinical and cadaver dissections, the superficial musculoaponeurotic system (SMAS) is seen to become the investing fascia of the zygomaticus major and minor muscles in the medial cheek. The pull on the cheek flap during rhytidectomy is diffused by the attachment of the SMAS to these muscles. I believe that this attachment accounts for the minimal change in the nasolabial crease after a Skoog-type sub-SMAS face lift.     

The high-superficial musculoaponeurotic system technique in facial rejuvenation: an update

The medical charts of 267 patients who had primary high-superficial musculoaponeurotic system (SMAS) rhytidectomies were reviewed. The depth of the nasolabial fold was used as an indicator of the degree of descent of the subcutaneous cheek mass, as a guide in procedure selection, and as a method of judging the operative results. Fold depth was assigned a score of 0 to 3, with 3 being most severe. According to their preoperative fold depth, patients were operated on using one of three variants of the high-SMAS technique: sub-SMAS dissection up to the nasolabial fold, sub-SMAS dissection up to the nasolabial fold plus transnasal SMAS graft, or sub-SMAS dissection across the nasolabial fold. An independent trained observer rated the postoperative fold depth in each case from photographs taken at the 6-month follow-up visit. Of patients with fold scores of 2 or 3, 97 percent (183 of 189 patients) showed visible improvement in nasolabial crease depth after the operation.     

The superficial musculoaponeurotic system in the upper lip: an anatomic study in cadavers

Ten cadavers were employed to demonstrate the presence of the SMAS in the upper lip using macroscopic and microscopic techniques. The relationships and attachments of the SMAS to the dermis of the upper lip are described. In cadavers, medial traction on the SMAS in the upper lip in conjunction with superolateral traction on the SMAS in the cheek is found to decrease the depth of the nasolabial fold. Superior traction on the SMAS in the upper lip elevates the interlabial line, reestablishes the convexity of the lateral vermilion border, and partially increases concavity of the profile.     

The midface sling: a new technique to rejuvenate the midface

In the early 1990s, the midface became the focus of facial rejuvenation, and various techniques effected elevation by plicating, or on, the midface. Recent analyses of facial aging demonstrate that selective ptosis of the midfacial tissues lateral to the nasolabial fold results in an infraorbital hollow and deepening of the nasolabial fold. Therefore, the authors propose that the midface, from the lower portion of the cheek mass, will result in superior midface positioning. Since 1996, the authors have elevated the midface in select patients by placing a sling of prosthetic (Gore-Tex) or autogenous (tendon or fascia) material through the cheek mass. The sling is secured medially to the infraorbital rim using a nonabsorbable periosteal suture or a mechanical anchor. As variable tension is applied laterally toward the superficial temporal fascia, the sling functions as a fulcrum to return the cheek mass to a more youthful anatomical position. Elevating the cheek mass in this fashion fills the infraorbital hollow and results in amelioration of deep nasolabial folds and jowling. With a mean follow-up of 18 months, 50 patients treated with the midface sling report satisfaction with the procedure. There have been no instances of nerve damage, infection, or hematoma in the midface. None of the slings have required removal and ectropion has not occurred. Because of postoperative asymmetry in one patient, additional elevation of the ipsilateral cheek mass was performed by increasing the tension on the lateral cheek portion of the midface sling. Mathematical models demonstrate the biomechanical superiority of lift through the use of multiple vectors as compared with linear pull techniques. In this fashion, the midface sling supports the cheek mass, providing rapid, simple, and secure elevation. Because of the limited subcutaneous dissection, there is a reduced risk of facial nerve damage and cutaneous vascular compromise. Unlike with other techniques, the lateral portion of the sling may be easily identified through a small incision in the temporal scalp, facilitating subsequent postoperative adjustment of the midface suspension. Furthermore, because the entire cheek mass is permanently supported with an inelastic sling, the results may last longer than those with techniques that rely on sutures to plicate or lift portions of the superficial musculoaponeurotic system.     

Multiplane face lift with the subperiosteal dissection for orientals

A subperiosteal face lift rejuvenates the midface and periorbital region by restoring facial muscle tone. Since 1993, the authors have performed this procedure on Oriental patients who have their own distinct facial contours: the brachycephalic cranium and a prominent zygoma and mandibular angle. Although it was thought that these protuberances might disturb the subperiosteal procedure, especially in the anterior midface, the procedure could be performed easily by adopting the ancillary upper buccovestibular and subciliary incisions; the authors found that the protuberances actually act as fulcrums to keep up the lifting vectors reliably. For older patients, the procedure was combined with a deep subcutaneous dissection. A simple lift of the periosteum would not improve a severe nasolabial fold deformity and prominent wrinkles adequately because of "lag-lifting" of the superficial layer. It was concluded that the multiplane face lift, consisting of the subperiosteal and the deep subcutaneous approaches, achieves a natural-appearing rejuvenation of the Oriental aging face.     

Anatomic variations of the nasolabial fold.

The nasolabial fold varies considerably from person to person. Three main groups may be distinguished: convex, concave, and straight. It is the muscles of smiling that are directly responsible for the shape and depth of the fold, and in their absence of function, as in facial palsy, the nasolabial fold disappears. Cadavers were selected in accordance with the nasolabial fold they presented and were dissected to analyze the difference in underlying anatomy between one fold shape in one cadaver and another fold shape in another. The study demonstrates that the nasolabial fold is the result of a conflict between soft and dynamic tissues of the middle face or an interaction between the skin and fat envelope on one side and the underlying muscles on the other. The greater this conflict, the more excess there is of cheek skin and the more pronounced a nasolabial fold. The mechanism that creates the nasolabial fold and the anatomy of the fold are described in this paper.     

A 5-year study of the transmalar subperiosteal midface lift with minimal skin and superficial musculoaponeurotic system dissection: a durable, natural-appearing lift with less surgery and recovery time

The transmalar subperiosteal midface lift is a simple, direct-approach procedure to be performed with a meloplasty. The entry into the midface is at the site of maximum suture tension, which allows for more elevation. The skin is elevated enough to expose the entry site, which is on the zygoma just cephalad to the origins of the zygomaticus muscles. Through a small hole at that site, a periosteal elevator is used for the midface dissection. This is a blind dissection, and the technique is described. The advantages of the technique are that there is (1) no lower-lid incision or risk of an ectropion, (2) a resultant tightening and elevation of the lower lid, (3) more elevation and durability because the zygomaticus muscle origins are elevated with the periosteum and are sutured to the very substantial deep temporal fascia, (4) a simple and fast procedure, and (5) no telltale sign of a face lift. Both the superficial musculoaponeurotic system (SMAS) and the skin are substantially elevated with the transmalar subperiosteal midface lift to the extent that they should be only minimally dissected. In the author's opinion, the extended dissection of the skin and/or the SMAS does not increase the amount of tissue lift and probably reduces it in most cases, considering that the goal is a natural look and not one that appears pulled or stretched. The skin is elevated only for exposure, and the SMAS is elevated only enough to create a preauricular SMAS-platysma flap to tighten the neck. With two fewer layers of dissection, there is significantly less postoperative swelling and recovery time. The article presents the technique, the results on 272 patients over a period of 5 years, and a discussion. No patients described have had secondary procedures such as lasers, so the transmalar subperiosteal midface lift can be evaluated on its own merit.     

A challenge to the undefeated nasolabial folds

Previous attempts to improve the nasolabial folds have been disappointing. By extending the face lift skin dissection to the nasolabial fold and up onto the malar prominence, reducing the fat of this fold by excision, and applying direct posterior retraction to the freed facial skin, rather dramatic improvement in the nasolabial folds have been achieved. This is a preliminary report with a follow-up of 8 months or less.     

Combined rhytidectomy and full-face laser resurfacing

A series of patients undergoing a combined face lifting procedure with simultaneous laser resurfacing is described. Although resurfacing is accepted as safe for deep-plane face lifts and forehead lifts, there are reports of preauricular skin loss with a standard face lift. In this series, 26 consecutive cases are described. A superficial musculoaponeurotic system (SMAS) face lift technique was used. A skin flap was developed no more than 3.0 cm from the preauricular area, and most of that was excised. Full-face laser resurfacing was done with the SilkTouch laser. An 8-mm square pattern was used at 16 to 18 W. Three to four passes were done. Care was taken, however, to do very superficial lasering of the periphery, especially over the small amount of undermined skin that remained. There was no preauricular skin loss. This series demonstrates the safety of combining laser resurfacing with the SMAS technique face lift in regard to preauricular skin loss.     

Anatomicohistologic study of the retaining ligaments of the face and use in face lift: retaining ligament correction and SMAS plication

Plastic surgeons have sought to improve nasolabial folds, jowls, jaw lines, and cervical contour with face-lifting procedures that are abundant in the literature. The retaining ligaments of the face support facial soft tissue in normal anatomic position, resisting gravitational change. As this ligamentous system attenuates, facial fat descends into the plane between the superficial and deep facial fascia, and the stigmata of facial age develop. In this study, surgical correction of the retaining ligaments and plication of the superficial musculoaponeurotic system (SMAS) to reposition the structures that have descended with gravitation are discussed. The anatomy of the facial retaining ligaments was studied in 22 half-faces of 11 fresh cadavers, and the localization, extension, and width of the ligaments were examined macroscopically and histologically. Surgical correction of the retaining ligaments and plication of the SMAS have been accomplished in 27 face-lift patients with this anatomicohistologic study taken into consideration. There was hematoma in one patient at the cheek region and a permanent dimple caused by postoperative edema in two patients, with a localization of one zygomatic and two parotidomasseteric ligaments. In one patient, hypesthesia in the mandibular nerve region was seen, which remitted at 14 weeks. There were no other complications, and with a follow-up of 24 months, excellent aesthetic results and a high level of patient satisfaction were encountered.     

Reconstruction of large nasal defects with a combination of local flaps based on the aesthetic subunit principle

Herein is described a technique that uses a combination of local flaps to reconstruct large defects involving the nasal dorsum and cheek. The flaps used are a transposition flap elevated from the area adjoining the defect and bilateral cheek advancement flaps. This technique leaves all suture wounds at borders of the aesthetic subunits that have been described previously. Color and texture matches were good and symmetrical. The transposition flap can be modified according to whether the defect includes the nasal tip. After raising the cheek advancement flap, it is also possible to use a dog-ear on the nasolabial region for any alar defects. Nine patients were treated using this procedure. The technique is very reliable (no complications such as congestion and skin necrosis in our series) and is easy to perform. One patient had palpebral ectropion after the operation and underwent secondary repair. In this series, defects measuring 45 x 30 mm in maximum diameter and including the nasal dorsum, nasal tip, ala, and cheek were treated.     

The nasolabial fold: an attempt at synthesis

There is now enough information on the nasolabial fold to try to synthesize it with other well-known structures, such as the dermal terminations of the facial muscles, the superficial musculoaponeurotic system, and the fat pad. Rest dynamic equilibrium is a good concept to use to understand the nasolabial fold, because the nasolabial fold is not a passive, definitive structure, but an evolutive border whose limits depend on the absence or presence of fibromuscular terminations crossing the superficial musculoaponeurotic system of the cheek. A simple photograph of two men will help illustrate the difference between the convex and the concave nasolabial fold.     

The submuscular aponeurotic system (SMAS): a histologic and comparative anatomy evaluation

The submuscular aponeurotic system (SMAS) has been steeped in controversy. The goal of our anatomic study was to further clarify the existence of the SMAS. With an operating microscope, we performed dissections in 10 fresh cadaver heads (20 hemiheads) exposing the SMAS through a face lift incision. Through the operating microscope we were able to identify the SMAS and its relationship to other anatomic structures. Full-thickness longitudinal sections were obtained for routine histologic studies along various surgically relevant regions of the SMAS. In addition, dissections were accomplished with the operating microscope on 12 rhesus monkey fetuses ranging in age from a few weeks to 8 months. Data obtained from the fresh cadaver microdissections, topographic histology, and comparative anatomy revealed the presence of the SMAS as a distinct fibromuscular layer composed of the platysma muscle, parotid fascia, and fibromuscular layer covering the cheek.     

Evaluation of a technique designed to correct nasolabial folds.

This is a long-term follow-up of correction of nasolabial folds in conjunction with face lift that was first published in 1987. In the last 200 face lifts, nasolabial lipectomy has been carried out in 90 percent. Refinements and extensions of the procedure are also described with case illustrations.     

Composite rhytidectomy.

Signs of aging in the face reflect the change in position of deep anatomic elements, which are the platysma muscle, cheek fat, and the orbicularis oculi muscle. These changes occur from progressive ptosis of these elements, which continue to keep their intimate relationship with each other throughout the aging process. Conventional face lift procedures disrupt this normal relationship by separating the skin from these elements. All SMAS techniques reposition only the platysma muscle without repositioning the cheek fat and orbicularis muscle. This composite rhytidectomy allows elevation of a composite musculocutaneous flap containing all three elements for repositioning while maintaining their intimate relationship with each other and with the skin. One-hundred and sixty-seven composite rhytidectomies have been done with impressive results and minimal complications.     

Restoration of the upper lip and nasolabial area by means of an intraoral approach

Superomedial repositioning of the superficial musculoaponeurotic system (SMAS) in the upper lip is accomplished by means of intraoral incisions. The procedure reestablishes the convexity of the lateral vermilion border, elevates the upper lip, and restores a more youthful appearance to the upper-lip profile. Depth of the nasolabial folds are reduced. We have performed this procedure on 14 patients. Follow-up intervals range from 6 to 20 months, averaging 14 months. All patients received concomitant rhytidectomy; usual operative time was increased by 20 minutes. Results have been rated good to excellent by patients and surgeons. There have been no recurrences of nasolabial fold deepening or upper lip depression, and there have been no complications. In selected patients, this procedure, along with rhytidectomy, may provide a more youthful appearance.     

Subperiosteal approach as an improved concept for correction of the aging face

A harmonious facial appearance is determined by a balanced relationship among all tissues of the face. With advancing age, balance is lost among the bone, muscle, fat, and skin as progressive changes occur in their volume, shape, position, and consistency. Study of clinical cases and fresh cadaver dissections has led to better understanding of the superficial musculoaponeurotic system (SMAS) and its relationship with the facial muscles and their bony insertions. From these anatomic studies we have developed an improved concept of rhytidectomy with the subperiosteal detachment of all soft tissues from the orbit, upper maxilla, malar bone, and nose. Following this detachment, the soft tissues of the cheek, forehead, jowls, nasolabial folds, lateral canthus, and eyebrows can be lifted to reestablish their youthful relationship with the underlying skeleton. Our 4-year experience includes 105 patients. Sixty percent of these patients were admitted to the hospital and had their procedure under general anesthesia; forty percent, however, had their procedure in an outpatient setting requiring only local anesthesia (lidocaine hydrochloride 1% plus epinephrine) and intravenous sedation (midazolam, ketamine). Complications have been minimal except for temporary paralysis of the frontal nerve in seven patients; guidelines for prevention have subsequently been developed. The subperiosteal rhytidectomy is excellent and appears more natural for rejuvenation of the upper and central face, eyebrows, periorbita, external canthus, cheeks, and nasolabial fold.     

Lip augmentation with superficial musculoaponeurotic system grafts: report of 103 cases.

Many patients suitable for a lip augmentation are of face lift age, and could benefit from a simultaneous lip enhancement during the rhytidectomy procedure. The healthy, live superficial musculoaponeurotic system (SMAS) tissue obtained from the face lift can be recycled and grafted with minimal additional operating time. From April of 1995 to January of 2000, 103 patients (99 women and four men) underwent a lip augmentation procedure by the senior author (N.L.) using SMAS grafts harvested from a simultaneous rhytidectomy. Indications for surgery were purely aesthetic in all 103 cases. The surgical technique used for the SMAS graft lip augmentation is as follows: Using a narrow tenotomy scissors, an intramuscular tunnel was created with blunt and sharp dissection across the lip. The graft, obtained from the posterior edge of the SMAS dissection, is left as long as possible, and is pulled through the tunnel with a tendon forceps. The lips are then stretched manually from the central point upward and downward, respectively. It is important to avoid suturing the ends of the graft into the closure; the grafts should be allowed to move freely, to avoid postoperative tethering on smiling or mouth opening.Most patients expressed some initial concern with their early appearances caused mainly by the swelling. By 2 weeks, most patients were extremely pleased with the size and shape, and their main concern was that the lip fullness would shrink even more. By 3 to 4 weeks, shrinkage largely ceased and the correction remained for varying periods, some as long as 5 years. A sampling of the results was obtained by means of a questionnaire mailed to all patients having undergone the SMAS graft lip augmentation. Fifty-four patients (52 percent) returned the questionnaire with their responses. Of those who responded to the survey, 42 patients (78 percent) reported fuller lips than before their operation. Significantly, 11 of 14 patients (79 percent) followed up after 24 months postoperatively reported fuller lips and excellent or good results. Complications and unsatisfactory results were very rare, occurring generally at the beginning of the learning curve of the series.SMAS grafts are useful for long-lasting lip augmentation, producing a youthful appearance by adding natural, soft roundness and fullness to lips without the artificial look and feel of synthetic material.