image of silk fabric and dry skin

B.R. Moody1, MD and R. Sengelmann2, MD

1 Vanderbilt University, Nashville, TN, USA
2 Washington University, St. Louis, MO, USA


Numerous adaptations of face-lift techniques have been devised, and each surgical approach has its own risks and benefits, as well as proponents and detractors. All of the conventionally accepted techniques achieve removal of redundant skin. However, it’s the variations in approach to the deeper soft tissue structures that separate the many face-lifting procedures. A skin only face-lift was the earliest form of surgical rhytidectomy, but failed to achieve significant long-term benefit. Cosmetic surgeons of various backgrounds thus sought to achieve a more durable benefit from the surgery. While certain techniques have been classically ascribed to a particular surgeon, innovation does not occur in a vacuum and many surgeons are responsible for our current state of knowledge with regards to facial rhytidectomy surgery.

Key Words: face-lift, rhytidectomy

An appreciation of the concept of the superficial musculoaponeurotic system (SMAS) occurred in the 1970s.1 SMAS manipulation is a common approach to face-lifting, and appropriate modification of the SMAS can produce long lasting esthetically pleasing results. SMAS rhytidectomy begins with the creation of a cheek skin flap. The SMAS is handled in a number of ways. The simplest approach is to plicate the SMAS. The plication approach relies upon folding the SMAS onto itself without SMAS undermining. This technique tends to be a very safe approach to face-lifting as the SMAS and sub-SMAS structures are left intact.2,3

Baker popularized the lateral SMASectomy approach. His method, similar to plication, does not undermine the SMAS; rather, a strip of the SMAS overlying the parotid gland is resected. Using large absorbable sutures, the resected edges of the SMAS are joined, thereby elevating the lower portions of the SMAS. Baker’s technique is also very safe as the facial nerve is protected by the parotid gland in the area of SMAS resection.4 More extensive SMAS management is obtained by creating a limited SMAS flap (conventional SMAS face-lift) or an extended SMAS flap. The SMAS flap is created in addition to the skin flap, and is separately repositioned.

While SMAS modification remedies many of the problems with the skin-only rhytidectomy, some surgeons felt that key elements of the aging face were inadequately corrected. Concern with the ability to adequately reposition the nasolabial fold and elevate the midface led to further surgical modifications. Techniques to reposition deeper tissues were developed, and this process culminated in the composite rhytidectomy.

In the late 1960s, Skoog described a sub-platysmal plane of dissection that left the skin and platysma together as a single unit. Skoog’s initial work prompted surgeons to create deeper planes of dissection. The deeper tissues were left attached to the overlying skin and repositioned as a single unit. In the early 1990s, Hamra described the composite rhytidectomy. This technique involves creating a deep plane of dissection for tissue suspension. A unified flap that consists of skin, platysma, midface cheek fat and orbicularis is created, elevated, and repostioned. This approach seeks to add, among other things, cheek fat and nasolabial fold correction into the facelift procedure.5 Concern has been expressed with regard to the relatively long recovery period from these deep plane dissections.3 Figure 1 illustrates the planes of dissection in the traditional face-lift techniques discussed, while Table 1 summarizes various rhytidectomy approaches.

Face-Lifting: An Overview - image
Figure 1: Illustration of dissection planes of traditional face-lift approaches.
Used with permission from Lippincott, Williams & Wilkins.5

Face-Lift TechniqueEssential FeaturesComments
Skin OnlySkin flap created. No manipulation of deeper tissues.Limited benefit.
SMAS PlicationSkin flap created. SMAS is folded on itself. No SMAS undermining.Straightforward, limited anesthetic requirements.
S-Lift and VariantsSkin flap created. SMAS is plicated with purse string type sutures. No SMAS undermining.Similar to SMAS plication with sutures elevating the SMAS and platysma. Limited anesthetic requirements.
Lateral SMASectomySkin flap created. SMAS overlying parotid is resected and tightened. No SMAS undermining.Little risk of nerve injury. Limited recovery time.
Skin flap created. Separate SMAS flap created. Flaps advanced independently.Increased risk of nerve injury. Benefit over plication alone is uncertain.
SMAS Lift (extended)Skin flap created. Separate SMAS flap created. Flaps advanced independently.Similar to conventional SMAS lift with greater degree of SMAS flap undermining.
Single flap of skin, orbicularis oculi, cheek fat, and platysma is created. Flap advanced as a single unit.Successor to “Deep Plane” face-lift. Relatively long recovery period. Addresses midface descent. Increased risk of nerve injury.

Table 1: Summary of rhytidectomy approaches.

As face-lift approaches multiplied and became more complex, patient desires changed. Younger patients began to seek cosmetic surgery and trends toward less invasive approaches to facial rejuvenation developed. Patients wanted less downtime from their procedure. Additionally, despite increased tissue rearrangement with more complex surgery, a clear and compelling benefit of one type of face-lift over another failed to materialize. While controversial, the few studies that directly compared the various techniques failed to show a significant difference in outcome.3,6

The desire for a less invasive face-lift prompted techniques such as Saylan’s “S-lift” and Tonnard’s “Minimal Access Cranial Suspension” face-lift. These approaches rely upon a limited face-lift incision, conservative skin flap creation, and the use of sutures in a loop configuration to plicate the deeper tissues. No SMAS flap is created. Local anesthesia (with or without oral or IV sedation) is all that is required for these ambulatory, and in many cases office-based, procedures.7,8 In many cases, these limited approaches are augmented by the use of adjuvant procedures such as botulinum toxin injections, laser skin resurfacing or chemical peeling, fat transplantation, and soft tissue fillers to achieve the desired result through multiple small interventions rather than one more involved procedure. Figure 2 shows a patient before a Minimal Access Cranial Suspension face-lift and at 1-year follow up.

appearance prior to suture plication rhytidectomy modeled after Tonnard’s “Minimal Access Cranial Suspension.Intraoperative view. Subcutaneous plane of dissection illustrated along with placement of a permanent suspension suture.One-year postoperative view. Noticeable sustained improvement in jawline.
Figure 2a. Preoperative
appearance prior to suture plication rhytidectomy modeled after Tonnard’s “Minimal Access Cranial Suspension.”
Figure 2b. Intraoperative view. Subcutaneous plane of dissection illustrated along with placement of a permanent suspension suture.Figure 2c. One-year postoperative view. Noticeable sustained improvement in jawline.


These less invasive approaches have been favored by dermatologic surgeons. The popularity of these procedures stems from several factors. The procedure is performed on an outpatient basis, utilizing tumescent anesthesia and occasionally with moderate oral, IM, or IV sedation. Recovery from these procedures is relatively rapid and can be seen in a matter of a few days to weeks. Complications are few and minor. In Saylan’s original series, he noted that the most frequent complaint was short-term pain and tightness in the pre-tragal region. Temporary facial nerve palsy was observed in three secondary face-lift patients. The platysmal plicating suture caused temporary dimpling beneath the earlobe in most patients.7 In their series, Tonnard and colleagues also found this approach very safe. They noted that most patients returned to normal activity within one week.8 Both Saylan and Tonnard feel that their patients are achieving lasting benefit from this approach.9,10

A number of face-lift alternatives and adjuvant procedures have been recently popularized. For the patient with primarily soft tissue ptosis and little skin redundancy, the use of percutaneously placed suspension sutures is an option. This approach has been proposed for elevation of the brow, midface, and jowl regions.11,12 The advantages of these procedures are the use of local anesthesia and minimal scarring, downtime and expense when compared with traditional surgical rhytidectomy. As no skin excision occurs, these techniques will not remove redundant skin and may be best suited for younger patients. Most surgeons using suspension techniques utilize a variety of nonabsorbable sutures. Recently, a specially modified polypropylene suture with sharp, barb-like projections has been described. These percutaneously placed sutures, dubbed APTOS threads, serve to securely grasp and elevate soft tissues.13 Table 2 summarizes the most promising minimally invasive techniques.

TechniqueEssential FeaturesComments
Radiofrequency energy
Contact cooling with no epidermal disruption. Seeks to achieve skin tightening.New technology. Limited data to date. Simple to operate. Topical anesthetic only. No downtime.
Percutaneous Suspension Sutures (including APTOS)Uses suture material to suspend ptotic soft tissues.Does not address skin redundancy. Uncertain long-term correction. Local anesthetic only.

Table 2: Summary of the most promising minimally invasive facial rejuvenation techniques.


While the myriad of options for face-lifting may seem confusing to physicians and patients at first glance, there are advantages and disadvantages to each. With more options available, we can cater our treatments for each patient. With proper education and a firm preoperative assessment of goals, the surgeon and patient can select the approach that optimizes their probability of a successful outcome. Clearly there is no one solution to all forms of facial aging.


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