The Aesthetic Center For Plastic Surgery to set up a consultation
or receive additional information:
A. MENTZ, III, MD, PA, FACS, FICS
The Aesthetic Center For Plastic
Surgery, LLP Founding Partner
- 1976-1980 Louisiana State University,
Baton Rouge, Louisiana Bachelor of Science
- 1980-1984 Louisiana State University
Medical School New Orleans, Louisiana, Doctor
- 1984-1986 Ochsner Foundation
of New Orleans, General Surgery
- 1986-1989 Tulane University
School of Medicine, Otolaryngology - Head
and Neck Surgery
- 1989-1991 St. Joseph Hospital
of Houston, Plastic and Reconstructive Surgery
- The American Board of Plastic Surgery
American Board of Facial Plastic and Reconstructive
American Board of Otolaryngology - Head and
- American Society of Plastic Surgeons (ASPS)
- American Society for Aesthetic Plastic Surgeons
- American Society of Facial Plastic and Reconstructive
- Lipoplasty Society of North
- American Academy of Otolaryngology Head
and Neck Surgery (AAOHNS)
- Fellow, American College of Surgeons (FACS)
- Fellow, International College of Surgeons
- The American Medical Association
- Texas Medical Association
- Houston Society of Plastic Surgeons
- Harris County Medical Society, Houston
- Aesthetic Surgery, Face and Body, Certified
- Micro Surgery, Certified
- Laser Srugery, Certified
- Endoscopic Surgery, Certified
- Ultrasonic Liposuction, Certified
- Aesthetic Surgery, Face and Body - Certified
- Micro Surgery - Certified
- Laser Surgery - Certified
- Endoscopic, Sinus, Forehead, Face, Abdominal,
Breast - Certified
- Ultrasonic Liposuction - ASPRS Certified
- Louisiana 1984-1994
- Texas 1991-Present
St. Lukes Episcopal
· Memorial Hospital
SW · Methodist Hospital
Memorial City Medical Center · Columbia Womans Hospital of Texas
Bayou City Medical Center ·
Memorial Hospital - Memorial City Texas Childrens
Hospital · Health
South · Columbia
Bellaire Medical Center Columbia West Houston
Medical Center · Memorial Hospital NW St. Joseph Hospital
· West Houston Medical
PUBLICATIONS and PRESENTATIONS
More than 25 publications
and presentations including
- Multilayer Facelift - A book chapter in
Operative Plastic Surgery 2000.
- The original and first publication of Abdominal
- The first presentation of Modified Abdominal
- Three dimensional structure rhinoplasty.
- Endoscopic Brow-lift techniques.
- Endoscopic Facelift techniques.
- Large volume liposuction
- Long-term effects of liposuction.
- Newest Tecniques for Facial Rejuvenation
- Top Doctor Recognition Houston Texas
- Mortar Board Honor Society, LSU, 1980
- Aesculapian Honor Board, LSU Medical School
- President, Senior Medical School Class,
- Officer, Ochsner Resident Program
- Chief Resident, Tulane, Head and Neck Surgery,
- Chief Resident, St. Joseph Plastic Surgery,
- Chief, Plastic Surgery Division, Sharpstown
General Hospital, 1994-1996
- Laser Safety Officer, 1995-1996
- Chief, Department of Surgery, Sharpstown
General Hospital, 1994-1996
- American Association for Accreditation of
Ambulatory Surgery Facilities (AAAASF)
- Safety Inspector, operating rooms, 1996
- Officer, Houston Society of Plastic Surgery
- Listed in Whos Who in Medicine
- Listed in the ABMS Directory of Board Certified
- ASAPS - Certification of Advanced Education
in Cosmetic Surgery
- AMA - Physician Recognition Award
- Active on two breast implant research teams
- President, Houston Society of Plastic Surgeons,
- Clinical Assistant Professor, Department
of Plastic Surgery Baylor College of Medicine
- Clinical Assistant Professor, Department
of Plastic Surgery St. Joseph Hospital
Dr. Mentz is a founder and partner of The Aesthetic
Center for Plastic Surgery, one of the largest
private plastic surgery teams in the country specializing
in aesthetic surgery. His extensive training and
magnitude of experience have merited Triple
Board Certification. He is the first surgeon
in the United States to hold these three boards.
His distinguished credentials in facial rejuvenation
with special interest in body contouring have
proven his commitment and enthusiasm for the specialty
of plastic surgery. He has held memberships in
all of the esteemed plastic surgery organizations
(ASPRS, ASAPS, FICS, FACS, AAFPRS) and
maintains staff privileges at Houstons most renowned
Dr. Mentz has dedicated the last 15 years of his
career in medicine to the art and science of aesthetic
plastic surgery. The media has recognized him
locally and nationally on local radio shows, Channels
11,13 and 51, and publications of Longevity Magazine,
Beauty Magazine, Robert Kennedy MuscleMag, International
MuscleMag, Health and Fitness Magazine, Texas
Woman magazine, and the Houston Post and Chronicle
Newspapers. He attends many meetings, lectures
nationally and internationally and is on the teaching
staff at two major residency programs in Houston.
Over the years he has been able to analyze and
improve his results, reinforcing the theory that
experience is the best teacher. His clinical
experience is devoted 100% to aesthetic surgery.
When in surgery, your safety is his number one
The ultimate goal for you is to create a natural
and youthful appearance with minimal detectability
and risk. Dr. Mentz and his dedicated staff
strive to provide that Added Touch to maximize
your experience and make it as comfortable and
refreshing as possible. To accomplish this The
Center offers a full spectrum of ancillary
services to speed your recovery and improve your
results. Dr. Mentz would like to become a partner
with you in your pursuit and make this experience
one of the highlights of your life.
Henry A. Mentz, MD, FACS, FICS
The basic concept behind multilayer (composite, deep-layer,
or multivector) face lifting is twofold. The first concept is
that soft tissue sagging is best rejuvenated by repositioning
and suspension. This is in contrast to excision of the underlying
soft tissues and overtightening the skin to compensate for soft
tissue looseness. The second concept is that facial skin relaxation
and soft tissue decent occur at different rates and in different
directions. Rejuvenation of the face should then reposition
and tighten at separate tensions and in separate directions.
The skin in the cheek require flap movement posteriorly and
slightly cephalad and the cheek and jowl soft tissue requires
vertical repositioning and fixation. Skin and soft tissues of
the brow, cheek and neck must be treated separately to accomplish
full and natural rejuvenation.
The conventional facelift relies on skin tightening only and
fails to address the effects of aging and gravity on structures
deep to the skin. Underlying facial muscles as well as the fatty
deposits will sag and stretch. To accommodate for deep tissue
looseness several surgeons have recommended plication of the
soft structures or removal of fatty deposits. This was first
performed in the neck (Adamson, Horton and Crawford-1964, Millard,
Pigott and Hedo-1968) and then in the midface (Pennisi and Capozzi-1972,
Baker and Gordon-1969).
Actual deep layer undermining was not advocated until 1974 by
Skoog. Mitz and Peyronie used cadaver dissections to define
the superficial musculoaponeurotic system (SMAS) in 1976. Early
problems with deep lifting included early recurrence of skin
folds since the skin was attached to the deep SMAS flap. There
were several adaptations that included both skin and SMAS undermining
combined with SMAS repositioning (Owsley-1977, 1983,1985; Hamra-1984;
Lemmon-1983; McKinney and Tresley-1984). Treatment of lower
face and neck laxity advanced with many modifications of SMAS
and platysma suspension to create a muscular sling (Connell-1978,
Ashton-1979, Kaye-1981, Owsley-1983, Lemmon-1983, Hamra-1984).
Since the introduction of the composite rhytidectomy by Hamra
in 1992 there have been many adaptations and modifications of
deep level lifting. Hamra’s initial composite rhytidectomy included
limited skin undermining, wide midface SMAS elevation, orbicularis
repositioning and neck platysma treatment. Furnas and Stuzin
provided valuable information by defining the specific anatomy
of the frontal branch of the facial nerve and SMAS retaining
ligaments, particularly the zygomatic and masseteric cutaneous
retaining ligaments. When these ligaments are released the midface
SMAS can be better elevated and repositioned. Additional elevation
has been achieved by partially releasing the temporoparietal
mesentery (Stuzin-1989) and the neck platysma (Owsley-1983).
Further elevation of the midface SMAS through endoscopic malar
fat pad suspension can achieve still more SMAS excursion (Anderson
and Lo-1998, Mentz-1999). Since midface swelling is increased
with these maneuvers additional lower lid support is necessary
for preventing lower lid lag or ectropion. There have been multiple
modifications regarding the orbicularis muscle for suspension.
Better understanding of the anatomy of the facial nerve innervation
to the zygomaticus and orbicularis muscles has altered the original
SMAS dissection (Hamra-1998, Ramirez-1999, Mentz-1999). Many
surgeons have incorporated liposuction (Illouz and Fournier-1983,
Teimourian-1983, Hetter-1984, Lewis-1985) into the submental
lipectomy. The use of endoscopic surgery in the forehead and
midface (Fuente del Campo-1993, Isse-1994, Graham, Core-1995,
Ramirez-1996) has allowed for creative and effective suspension
techniques and reduction of scar length. Finally, the use of
skin resurfacing topical agents, laser, fat grafting and the
use of botulism toxin has allowed for improvement of surgical
The use of multilayer techniques is becoming more popular. Rationalizing
a more complex operation has been difficult and has been subject
to evaluation of additional risks and potential benefits. Kamer
in 1998 compared revision rates of skin only, SMAS flap and
deep plane rhytidectomies. With the same surgeon performing
all 892 facelifts the tuck or revision rate was 21.7% for skin
only, 11.4% for SMAS, and 3.3% for deep plane lifts.
In assessing the patient for rhytidectomy, two or more consultations
should occur. The first visit should include evaluation of the
patient’s medical history, along with assessment of their special
needs and goals. Special risks such as hypertension, heart disease,
smoking, bleeding dysfunction and specific medications are important
and will be discussed later. A thorough physical examination
should be performed. The condition of the skin, soft tissues,
and general anatomy should be noted.
The patient should be examined in a brightly-lit room. When
analyzing the aging human face, one must be aware that changes
are due to loss of skin elasticity and sagging of deep anatomic
structures. When examining a patient, the surgeon should evaluate
all related aging facial structures and understand the changes
that take place in each area. The patient is appraised while
upright for accurate analysis of the anatomy. After analysis
one should combine the patient’s wishes with surgical recommendations
to develop a preoperative plan and appropriate goal. A careful
explanation regarding features that will likely have significant
improvement and areas that may not improve at all.
Figure 1 The Aging Patient
The aging patient. With age the skin will loose elasticity and
wrinkle. The skin loosens in a direction transverse to the underlying
muscles. The soft tissues will descend with gravity and drape
between fixed retaining ligaments. Because of these differences
these structures are best lifted separately.
Facial aging occurs because of several
factors. These include degradation of skin quality, color and
elasticity, subcutaneous fat accumulation or atrophy, loosening
of deep layer, furrowing of skin overlying facial muscles, and
exposure of skeletal, muscular and glandular structures.
The forehead is often considered a single unit, which includes
forehead, brows and upper eyelids. Ptosis of the forehead, causing
lowering of the brow, is consistent and usually compatible with
the degree of the aging of the face. The corrugator muscles
are known to cause the vertical frown lines of the glabella,
and full or partial removal of the muscles may alleviate these
lines. Because the forehead is an integral part of the aging
face, the forehead lift can improve flap shift in any rhytidectomy.
While a more superficial subcutaneous facelift may not oblige
the surgeon to do a forehead lift, a midface SMAS lift will
likely create skin and soft tissue redundancy in the zygomatic
arch and lateral orbital area if the brows are not repositioned
at the same time. Doing the forehead lift will also allow the
surgeon to remove less eyelid skin during upper blepharoplasty.
Optimal rejuvenation of the upper eyelid typically requires
both browlift and upper blepharoplasty. Upper lid ptosis may
require levator aponeurosis plication. Lacrimal gland ptosis
at the lateral edge of the orbital rim may require pexy under
the rim. Individual goals for specific brow position should
be assessed. Allowing the patient to visualize several brow
positions with a hand mirror will help guide the surgeon.
Aging of the lower eyelids includes decent of the lateral canthus,
loosening of the lower lid supporting structures, bulging of
orbital fat, decent of the midcheek soft tissue and exposure
of the infraorbital rim and tear trough. The lower eyelids should
be assessed for skin laxity, lid laxity (snap test), dryness
(Schirmer test), lid and lateral canthal position, orbital fat
protuberance, malar prominence and tear troughing. Deep layer
midface repositioning will increase the risks of ocular problems.
Lower eyelid surgery has a significant potential for problems
such as scleral show, denervation of the orbicularis muscle,
ectropion, dry or scratchy eyes, hollow appearing eyes or flattened
midface or recurrent tear trough. Special risk factors include
large skin excess, loose lower lids, dry eyes, down sloping
lateral canthus, large excess of orbital fat, minimal malar
prominence (negative vector is less prominent than the cornea),
and a deep tear trough. To reduce problems, a surgeon must consider
conservative skin resection, eyelid tightening procedures, lateral
canthal elevation or repositioning, orbital fat pad repositioning
or resection, reducing exposure and trauma to facial nerve branches
and malar fat pad repositioning for support and aesthetics.
In the midface, aging appears as drooping of the soft tissues
and fat, and skin excess. As these structures of the cheek descend
there is exposure of the infraorbital rim and tear trough, accumulation
of skin and soft tissue above the nasolabial fold with the corners
of the mouth turning down and a bulging of the jowls. As soft
tissues descend they drape and gather between the SMAS retaining
ligaments. The midcheek structures may be elevated vertically
with SMAS repositioning to lift the malar and jowl fatty tissue
and the corner of the mouth. Release of SMAS retaining ligaments
allows greater excursion and adequate “shelving” of the malar
pad. A multilayer approach combining vertical soft tissue repositioning
and midface suspension with oblique skin tightening may provide
the best approach to this area. Prominent nasolabial folds should
be treated independently with a filler such as fat or facial
grafting to insure reasonable improvement.
The neck is an integral part of facial aging and must be addressed
to be in harmony with a rejuvenated face. Aging in the neck
can leads to skin excess, fatty accumulation or atrophy, platysmal
looseness, separation, or banding, and decent of the submaxillary
gland and laryngeal structures. Facial platysma must first repositioned
at the cheek in a vertical vector for adequate “shelving” of
the malar pad and repositioning of the jowls. The midline platysmaplasty
is performed secondarily so as not to pull down the midface
SMAS structures. The platysma may be transected medially, laterally,
or completely to maximize SMAS movement along specific vectors.
Medial transection allows more jowl movement, lateral transection
allows more cheek movement and complete transection allows maximal
flap shift. Excessive fat is conservatively trimmed and the
muscle bands in the midline may be excised or sutured together.
The lateral platysma is suspended in a posterior vector from
superficial cervical fascial covering the mastoid. The anterior
borders of platysma are approximated to cover the midline cervical
area with a platysmal supportive sling. The skin excess is undermined
and excised behind the ear.
Figure 2Facial Rejuvenation
Facial rejuvenation requires both skin tightening and soft tissue
repositioning. With multilayer face lifting the direction and
tension for each layer and portion of the face may be tailored
to each patient.
The indication for rhytidectomy is general skin and soft tissue
laxity. Patient motivation and goals must be evaluated. Two
simple tests may be utilized to assess patient desires and goals.
First, have the patient place four fingers vertically along
the temporal hairline to the ear. Does the patient sense improvement
with tension? If the patient does appreciate an improvement
then do the second test. Give the patient a hand mirror and
ask the patient to lie back in a reclining chair and relax.
If they are satisfied with this appearance as a final result,
then they may be a good candidate for facial rejuvenation. Computer
imaging also has an important role in evaluating patient objectives
and demonstrating surgical limitations. Unrealistic goals may
be a warning sign that the patient cannot be satisfied even
with a reasonable result.
Other contraindications to rhytidectomy include major bleeding
disorders, smoking, vascular diseases like Raynaud’s phenomenon,
unstable psychological conditions or significant anesthetic
risks. Medical problems such as diabetes mellitus, hypertension,
asthma, or thyroid disorders may be treated and controlled prior
to surgery. Those patients with controlled hypertension may
require special perioperative care. Preexisting scars or radiation
damage may also be a contraindication. More unusual contraindications
include progeria, Werner’s syndrome, Ehlers-Danlos syndrome,
and some diet medicines.
Smokers should stop two weeks before and after surgery. Aspirin,
aspirin containing products or nonsteriodal anti-inflammitory
drugs should be stopped two weeks prior to surgery. Patients
prone to hair loss may be pretreated with Rogaine. Patients
with prior history of Bell’s palsy or Herpetic sores have an
increase risk of recurrence and may be treated with antiviral
prophylaxis. The risk of postoperative hematoma is increased
in males and patients with hypertension, upper respiratory infection,
history of alcohol usage, gastrointestinal problems, or a smoking
A second consultation is necessary for informed consent, photos,
review of patient goals and the operative plan. Some preoperative
Avoid sun exposure, tobacco, and alcohol two weeks before surgery.
No aspirin, nonsteroidal anti-inflammatory drugs, estrogen compounds
or vitamin E two weeks before surgery.
No haircut should be done to allow better cover of the incisions.
If the patient dyes their hair, they should be treated one week
before surgery and wait until six weeks after surgery before
dying their hair again. Hair should be shampooed the night prior
Do not take any health food teas or vitamins two weeks before
surgery. Gingko, garlic, parsley, vitamin E, ginseng and others
may increase bleeding and bruising or create cardiac irritability.
Healthy food choices are advisable, including vitamin K rich
vegetables like collard greens, kale, broccoli, spinach and
alfalfa. Alfalfa capsules, vitamin K supplements or arnica are
sometimes utilized to decrease bruising.
The morning of surgery wash the face with a mild soap and do
not apply makeup.
Preoperative Clonidine may be given one hour prior to surgery
to reduce postoperative hypertension. It should be noted that
Clonidine increases the potency of anesthetic agents and narcotics.
The operation can be performed with local anesthesia and sedation
or with general anesthesia. It is up the surgeon and the patient
to decide which may be best. The operating room should be outfitted
with equipment necessary to care for any operating room emergency.
Comfortable surroundings, good lighting, appropriate instruments
are also necessary. Often lighting from both sides of the flap
will help define precise flap thickness. Endoscopes, drills,
headlights, suction, tumescent pumps may also be necessary.
The operating room table may be fitted with a separate headpiece
or a standard bed with a silicone doughnut will improve access
to the incision easier.
Patient Markings and Incisions
Immediately before the surgery the patient should be placed
into a sitting position and the eyelids, nasolabial folds, asymmetries
in the brow, cheek or jaw line, submental chin incision and
midline should be clearly marked. Once the patient is made comfortable
or is asleep the hair may be placed into rubber bands or greased
with KY or Vaseline and the marks may be placed for the facelift
incisions. This is best done prior to the local anesthetic.
There are four parts of the incision: 1) the temporal incision,
2) the preauricular incision, 3) the postauricular incision,
and 4) the occipitomastoid incision. Placement of the incisions
is very important and may vary depending on many factors. Flap
shift or skin recoil can advance the scar. Several techniques
can be utilized to account for this.
FIGURE 3 incisions
The preauricular incision is the most important component of
facelift incisions since it is the most visible. The incision
should accommodate for flap recoil or flap shift, because the
preauricular scar will advance away from the ear as the patient
heals. The helical portion is placed 1 mm closer to the ear
than the upper helical width. The lobular portion is placed
in the crease anteriorly and a 1 mm cuff of cheek skin remains
on the lower and posterior edge of the lobule. The pretragal
incision may be placed at the edge or in front of the tragus.
It is useful to place tension on the preauricular skin to duplicate
flap shift as the incision is marked.
The temporal incision extends approximately
5 centimeters above the helical root. It may be placed in front
of the hairline only if the temporal hairline is extremely high.
This placement will be more obvious and may be beveled toward
the forehead on both surfaces to allow hair to grow through
the incision. In most patients it can be placed 4-5 centimeters
behind the hairline (cutting parallel to the hair follicles)
to hide the scar. Although this method will elevate the temporal
hairline, it reduces scar detectability. In short haired individuals,
swimmers, tennis players, golfers, sailors or patients with
a lifestyle that may make this incision more visible the incision
may be zigzagged in the temporal hair to reduce the “show” of
a linear scalp scar. This application is also true for the occipitomastoid
incision and requires a few more minutes to do.
The preauricular incision is patterned around the ear and should
follow anatomic margins. The incision is best marked by gently
pulling the skin forward to duplicate the postoperative scar
advancement or flap shift. This incision is always closed without
tension to reduce scar widening.
The helical portion should be marked with tension and to match
the width of the upper helical width. The incision should then
contour along the curve of the helix to the tragal notch. The
tragal portion may be incised in front or at the edge of the
tragus. Incisions behind the tragus will distort the appearance.
The pretragal incision preserves the natural tragal dimensions
with a minimal scar and may best be utilized when the tragus
is large. The tragal edge incision will tend to flatten a prominent
tragus but the scar will be hidden as a highlight at the edge.
This incision is best utilized when there is a color mismatch
between the ear and the new preauricular skin. The lobular portion
of the incision can be used to reduce a long or stretched ear
lobule by removing a small lobular wedge. For normal sized earlobes
a 1-mm reserve of cheek skin may be left on the lower and posterior
edges of the lobe for reattachment at the closure. Either way
the most important step here is to set back the lobule at least
15 to 30 because flap shift and scar advancement will advance
the lobule some amount. If this is not done the lobule will
elongate and appear stretched or “pixie”. . In men, some surgeons
prefer to place the incision just behind the sideburn to preserve
the fair hairfree preauricular skin. The standard preauricular
incision may be utilized if the hair follicles in the area in
front of the ear are removed. This keeps bearded skin from growing
adjacent to the ear and is a less conspicuous scar. This can
easily be done by gently defatting and carefully applying the
cautery on low setting to the underside of the hair follicles.
Figure 4 Preauricular Incision
Closure of the preauricular incision should incorporate a lobe
setback of 15-30 in anticipation of the lobe advancement as
the patient heals.
The postauricular incision should be made
directly in the retroauricular sulcus. Carefully mark the sulcus
without lifting the pinna. Elevation of the pinna will pull
mastoid skin onto the ear, therefore leaving the mark outside
the sulcus on the mastoid skin. If the mark is placed on an
elevated concha it should be 2 to 3 mm onto the ear so that
when relaxed the incision lies in the sulcus. The flap shift
here is tangential to the incision and therefore does not advance
to the mastoid.
The occipitomastoid incision first must cross a hair free area
just behind the ear before reaching the mastoid hairline. This
incision is best hidden if begun at or above where the helix
touches the hairline. This is usually at the external auricular
canal level. However, the incision may have to be lowered if
the patient has a large amount of neck skin to be resected behind
the ear. The advancement and rotation of a large amount of cervical
skin (with the pivot point at the most posterior end of the
incision) may shorten the flap in the sulcus and leave a gap.
Correcting the gap by advancing postauricular skin anteriorly
will create skin bunching at the lobule. Consequently, when
planning to resect a larger amount of cervical skin, the incision
is placed lower on the mastoid. The remainder of the incision
may be placed either in the hair (an angle 90 degrees from the
postauricular incision prevents sharp angulation at the flap
tip) or at the hairline. The hairline occipital incision should
be used in patients with extreme neck laxity in order to reduce
postauricular baldness from excising to much hair bearing skin.
When the incision is placed in the hair (cutting parallel to
the hair follicles), the hairline border must be lined up as
well as possible at closure to prevent hairline stair stepping.
For active or shorthaired individuals the same considerations
apply when considering a zigzag occipital incision. All scalp
incisions should be made parallel to the hair follicles.
The submental incision for access to the anterior platysma and
submental fat should be as short as possible (usually 3 cm will
allow for a Deavor). It is best placed just behind the submental
crease, but not in the crease. The midline should be marked
prior to surgery.
Proper sequencing for closure will improve skin redraping and
place appropriate tension on each portion of the incision. This
is also true for SMAS fixation.
After the marks have been placed and the hair secured loosely
in rubber bands or smoothed with KY or Vaseline the operation
can proceed. Under local anesthesia 1% lidocaine with 1:100,000
epinephrine is used along the incisions and .25% lidocaine with
1:400,000 epinephrine is used in the area of proposed undermining.
Under general anesthesia a tumescent pump can speed the infiltration
process using a 1:200,000 epinephrine solution and a 25 gauge
spinal needle. If tumescent body liposuction has been performed
prior to the facelift the lidocaine infiltration should be kept
to a minimum or left out to reduce lidocaine toxicity. Infiltration
of each region 15 to 30 minutes prior to dissection will improve
vasoconstriction. Meticulous hemostasis is paramount. Ice placed
in sterile gloves can be used intraoperatively to reduce bruising
and swelling. Slight elevation of the head of the bed can also
reduce intraoperative swelling.
The procedural sequencing for facial rejuvenation begins with
the forehead then proceeds with eyes, then left and right facelifts,
and finally the midline neck. Eyelids are best done after the
brow to prevent overexcision of upper eyelid skin. Bilateral
facial SMAS repositioning must proceed the cervical platysmaplasty.
When neck tightening is done first it tethers the SMAS inferiorly.
This prevents optimal shelving of the malar fat pad and full
repositioning of the jowl.
When planning deep layer lifting and SMAS repositioning expect
postoperative midface swelling and SMAS recoil internally. This
may place increased weight and stress on the lower lid so that
lower lid support is necessary to prevent scleral show or ectropion.
The second important factor in preventing lower lid sequelae
is preservation of orbicular innervation. Since innervation
comes from facial nerve fibers, which arise from near the zygomaticus
muscle inferiorly, the lower lid dissection should not be continuous
with the facial dissection.
The lateral canthus may be elevated and tightened with a lateral
canthus suture (5-0 Vicril) placed through the longitudinal
axis of the lateral canthal tendon and suture this to the inner
wall of the lateral orbital periosteum. Hamra calls this a “transcanthal”
canthopexy. It can be placed more superior for enhanced elevation
of the lateral canthus. This canthopexy can provide a more youthful
orbital fissure shape by slanting the fissure slightly up and
will reduce complications from lax lids and temporary midcheek
swelling. It will orientalize the eyes for two to three weeks.
Figure 5 Transcanthal Canthopexy
A 5-0 Vicril is placed through the canthal ligament and anchored
to inner orbital periosteum. This suture will tighten the ligament
and elevate the lateral canthus. Combined with the malar fat
pad repositioning provides improved lower lid support.
After the browlift and eyelids are done
(the lower eyelids should be left open), the facelift incision
is made. The amount of subcutaneous undermining depends on several
factors. Patient age, skin laxity and quality, smoking history
and patient health may limit the amount of undermining to ensure
adequate blood supply for healing. In deep layer facelifting,
wide undermining may be less important in achieving optimum
results, while less undermining improves blood supply and allows
concurrent facial skin repositioning with SMAS elevation. Generally,
skin undermining should be just enough to allow skin redraping
without causing tethering defects or buckling of the skin. Patients
with prominent skin wrinkling will benefit from more extensive
Subcutaneous undermining in the cheek is most precisely performed
with a light on the flap for transillumination and a light in
the wound for dissection. An experienced assistant holds the
skin with skin hooks or Deavor and the surgeon applies counter
traction on the skin of the face while using a scissor to dissect.
Retraction and flap handling should be gentle and even. Dissection
should be under direct vision. Blind scissor pushing tends to
leave the skin flap uneven, streaky or too thick. The skin flap
should appear even, yellow and pebbled when transilluminated.
Cloudy or streaky flaps on transillumination are uneven. Uneven
flaps may leave skin irregularities. Flaps too thick leave the
SMAS layer too thin or perforated.
Figure 6 Four Hand Technique
Proper elevation of the skin flap requires 2 hooks or Deavors
in the wound. The surgeon places counter traction behind the
dissection and the scissor advances the dissection. A transillumination
and direct light assist in creating an even subcutaneous dissection.
Begin the undermining in the temporal area
by creating a pocket underneath the temporoparietal fascia and
above the deep temporal fascia in an area superior to the helix
level and out to 2 cm lateral to the eyebrow to protect the
frontal branch of the facial nerve. Under direct vision the
dissection may advance to the orbital rim. This can provide
release of the lateral orbital retaining ligament and create
a tunnel for the malar fat pad suspension. This thicker flap
provides better protection to temporal hair follicles.
The midface dissection is in a different plane. In this area
skin undermining is in the subcutaneous plane and overlaps the
deeper temporal dissection by 1 or 2 cm leaving a temporoparietal
mesentery to protect the frontal branch. This mesentery may
be backcut along the frontal branch of the superficial temporal
artery and the parietal branch may be ligated. The frontal branch
of the superficial temporal artery is just lateral to the frontal
branch of the facial nerve and can be used as a useful landmark
when it is necessary to backcut the temporoparietal mesentery.
This backcut will improve lateral elevation of the brow.
Figure 7 the Temporoparietal Mesentery
The temporoparietal mesentery may be backcut lateral to the
frontal branch of the superficial temporal artery to reduce
subcutaneous temporal dissection. The frontal branch of the
superficial temporal artery is just lateral to the frontal branch
of the facial nerve.
Subcutaneous undermining above the SMAS
is continued down onto the cheek to the anterior edge of the
masseter muscle. Wide undermining to the nasolabial folds may
only be necessary in patients with moduis area skin excess and
wrinkling. It is usually necessary to undermine over the malar
cheek pad in a vascular area called McGregor’s patch.
The neck dissection begins at the occipital incision and dissection
is initially carried next to the sternocleidomastiod muscle
to keep the flap thick in the hair bearing skin. At the ear
lobule level the dissection is superficial to the superficial
cervical fascia of the sternocleidomastoid muscle to protect
the great auricular nerve. The great auricular nerve will arise
from the posterior surface of the sternocleidomastiod and run
vertically toward the ear lobule deep to superficial cervical
fascia. The subcutaneous cervical dissection should be continuous
with cheek dissection and extended to the midline in the neck.
Figure 8 Great Auricular Nerve
The posterior dissection begins deep to the superficial cervical
fascia leaving the postauricular flap thicker above the lobe
level. Below the earlobe the dissection stays above the superficial
cervical fascia to protect the great auricular nerve. The nerve
is usually centered on the sternocleidomastoid 6.5 cm below
the earlobe and lies below the fascia directly on the muscle.
SMAS flap elevation begins over the parotid gland, staying superficial
to the parotidomasseteric fascia and one centimeter below the
zygomatic arch. Dissection extends downward and vertically along
the anterior edge of the sternocleidomastoid muscle. Gentle
vertical scissor spreading will allow careful separation of
the tissues. Care must be taken to protect the ophthalmic and
buccal facial nerve branches that are covered be the thin fascia
covering the masseter. The flap is transected one centimeter
caudal to the zygomatic arch and this backcut extends toward
the lateral canthus until the zygomaticus major muscle is visualized.
The backcut then turns toward the modius following the direction
of and overlying the zygomaticus major muscle.
Figure 9 Retaining Ligaments
Retaining ligaments. Zygomatic ligaments originate from periosteum
and insert into the dermis.
Masseteric ligaments originate from parotid
gland and the anterior border of the masseter muscle.
The malar retaining ligaments must be released. Careful dissection
proceeds here. In 15% of patients there are ophthalmic branches
superficial to the zygomaticus muscle and facial nerve fibers
connect the zygomaticus and orbicularis muscles. The facial
nerve typically courses underneath the zygomatic muscles and
splits there into two larger group fascicles. The lateral group
is typically 10 millimeters below the zygomaticus origin. This
group gives fibers to the zygomaticus muscles and continues
through to the orbicularis muscle entering perpendicular to
the muscle fibers. The neural fibers pass through the orbital
muscle, preseptal muscle and finally pretarsal muscle (Ramirez-1999).
Any separation of the zygomaticus origin, orbital orbicularis,
preseptal orbicularis or preseptal orbicularis may cause denervation.
Since the facial nerve fibers enter the zygomaticus muscle from
it’s deep surface, the dissection extends superficial to the
muscle over the malar prominence to release the remaining malar
retaining ligaments above the zygomaticus muscle. It is safe
to stay 10 millimeters below the origin, leaving this portion
connected to orbicularis muscle. This leaves continuous the
zygomaticus-orbicularis muscle mesentery (Hamra-1988). Connecting
the lower lid dissection to the facial dissection will break
this mesentery which contains orbicularis nerve fibers. The
SMAS backcut should remain 1 cm below the zygomatic arch and
1 cm below the origin of the zygomaticus muscle origin, extending
over the muscle inferiorly for 2 cm for release (Mentz-1999).
It is only necessary to extend the dissection just past the
malar and masseteric retaining ligaments. Usually finger palpation
while pulling the SMAS cephalically will guide the surgeon to
any remaining ligaments. The malar fat pad is the final releasing
point and is done either with a finger (Ashton) or scissor (Owsley).
The instrument is passed under SMAS and over the zygomaticus
muscles to release the malar fat pad at the top of the nasolabial
fold. More extensive release lower in the midcheek will not
substantially improve SMAS excursion or malar fat pad shelving
and will likely increase prolonged midface edema and denervation.
Since the ophthalmic facial nerve fibers enter the orbicularis
muscle from the deep and inferior surface and directly perpendicular
to the muscle fibers care should be taken to leave a mesentery
of tissue between the lower blepharoplasty and sub-SMAS dissections.
Figure 10 SMAS Elevation
The SMAS flap extends just beyond the masseter and malar retaining
ligaments. The backcut begins 1 cm below the zygomatic arch,
1cm below the zygomaticus origin and then continues inferiorly
over the zygomaticus major muscle.
After SMAS release, repositioning begins
with cephalic traction. The SMAS flap is repositioned first
with malar fat pad suspension, then zygomatic arch sutures,
and then SMAS division to the earlobe and cervical anchoring
of the posterior flap. The cephalic excess may be excised in
patients with strong zygomatic arches. For most patients the
cephalic excess may be overlapped or folded (Lambros) and sutured
for zygomatic augmentation. If the SMAS is thin or has little
fibrous content Stuzin recommends folding the flap over a 1
by 4-centimeter sheet of Vicril mesh before suturing to reduce
suture pull through. The axis of SMAS rotation is the medial
extent of the SMAS backcut below the lateral canthus.
Figure 11 Malar Fat Pad Suspension
Malar fat pad suspension sutures provide elevation of the SMAS
pivot point. The suture is fixed into the deep surface of the
malar fat pad and passes underneath the temporoparietal flap
and is anchored to temporal fascia.
Further SMAS elevation in the midcheek
can be achieved with suspension sutures elevating the rotation
axis of the SMAS flap (Anderson-1998, Mentz-1999). This is done
prior to SMAS cheek suturing. A 4-0 Ticron suture is placed
through the deep surface of the cheek fat pad just overlying
the zygomaticus major muscle. The suture is passed through the
lateral orbital rim endoscopic tunnel beneath the temporoparietal
fascia. It can be anchored to temporal fascia in a vertical
vector. A second suture placed in the deep surface of the cheek
fat pad is also passed and anchored at a more oblique vector.
The two suspension sutures anchor the cheek fat pad superiorly
and posteriorly and moves the SMAS rotation axis in a posterior
superior direction thus improving the midface soft tissue repositioning.
The advantage of distant fixation reduces the lateral canthal
bunching and downward tension on the lateral brow that may occur
with direct sutures in the lateral canthal area. Secondly, the
malar suture may be placed far more medially than a direct suture
and can provide a pivot point near the pupil. Thirdly, the distant
fixation elevates the pivot point from a lower level and may
provide a more direct advantage in elevation of the jowl.
The SMAS is split at the earlobe to allow bi-directional advancement.
Cervical suspension is achieved by advancing the posterior edge
of the platysma and SMAS flap and anchoring it posteriorly to
mastoid and superficial cervical fascia. The lower edge of the
platysma may be backcut for increased excursion of the cheek
SMAS. Transection should be at least 6 centimeters below the
mandibular border to protect the marginal mandibular nerve.
Following adequate cephalad elevation of midface SMAS and posterior
repositioning of the cervical platysma, the midline platysmaplasty
may be performed. Maximal relocation of the midface soft tissues
can be achieved by first tightening the cervical platysma posteriorly
and then plicating the medial edges of the platysma.
Cervical subcutaneous fat may be reduced en block, piecemeal
under direct vision, or by liposuction. Leave 2-3 mm of subcutaneous
fat over the platysma is necessary to prevent skeletalization
of the muscle and exposure of the submaxillary gland. It is
best to perform the cervical defatting after midface SMAS elevation
so that the subcutaneous fat has shifted prior to fat removal.
A defatted submandubular groove elevated with SMAS onto the
mandible may produce an irregular border and blunt the sternomastoid-mandibular
trough. Bernard recommends defatting the sternomastoid -mandibular
trough just behind the mandibular ramus to better define the
mandibular angle. Cervical fat deep to the platysma in the midline
may be trimmed conservatively. Leaving some deep fat can help
disguise a prominent or ptotic submaxillary gland.
The platysma may be sutured at the midline after some central
fat removal. The platysma muscle is backcut depending on the
desired results. Midline wedge excision at the cervicomental
angle deepens the angle and may further release the jowl. Lateral
platysma release is for patients with poorly defined posterior
jawlines and improves lateral flap shift. Full width platysma
transection is reserved for patients with full necks and provides
maximal SMAS excursion. Platysmal transection is performed at
least 6 cm below the mandibular margin and should not be performed
on patients with thin skin or little subcutaneous fat. The edges
of the cut margin must be beveled to yield a smooth contour.
Figure 12a,b, c Platysma Treatments
Platysmal treatment may require medial, lateral or complete
transection. The transection will further release the facial
SMAS and improve SMAS excursion. Medial release will allow more
jowl and cheek movement and sharpen the cervicomental angle.
Lateral release will allow more mandibular angle show. Complete
release will allow more mandible show and a sharper cervicomental
angle. Platysmal transection should be at least 6 cm below the
mandible and should not be done on lean necks.
Following the deep midface and cervical repositioning, the skin
excess may be excised and closed. Since the first area closed
will relax slightly as the adjacent areas around it are closed
begin with the temporal anchor stitch so that the facial incisions
will hold the least tension. Martin describes a six-step method
for anchoring and closure.
Figure 13 Six-Step Closing
Sequential skin closure allows proper flap shift and improves
skin tension balance. Suture 1 is at the helical root, 2 at
the apex of the postauricular flap, 3 at the temporal midpoint,
4 at the occipital midpoint, 5 above the tragus, and 6 below
The amount of cephalic skin movement is
estimated by moving the flap up and down against the ear. The
surgeon should utilize the least amount of cephalic rotation
necessary to achieve reduction of periorbital and perioral redundancy.
Excess rotation will unnecessarily raise the temporal hairline
and make it more difficult for the surgeon at the second facelift
to retain a natural hairline. No deep suture is necessary and
the skin closure should be at just greater than normal tension.
A T shaped incision allows accurate suture placement and facilitates
extension of the incision without cutting the suture. The first
point of suspension is placed at the skin above the helical
root using 4-0 silk or proline. The second point of suspension
is placed at the apex of the postauricular incision. The neck
skin is shifted parallel to the neck crease. This stitch is
under subtle tension. The third point of suspension will be
at the midpoint of the temporal incision and the fourth used
to line up the occipitomastoid hairline. Lining up the hairline
will be important in preventing a stairstep or notched hairline.
Overexcision will result in an unnatural hairline, occipitomastoid
baldness, flap compromise and wide scars. Neck contouring is
more dependent on lipectomy and platysmal suspension rather
than skin tightness. The mastoid skin is closed with half buried
vertical mattress sutures to avoid unsightly suture marks on
the hair free cervical side. Next the pretragal hollow is created
by removing some preparotid fat anterior to the tragus and defatting
the pretragal skin. In males the hair follicles are exposed
and cauterized on a low setting. Then suture five and six are
placed above and below the tragus with 6-0 suture. The remainder
of the incision is closed with 4-0 in the hairline, 5-0 in the
postauricular sulcus and 6-0 in the preauricular area. Drains
may or may not be used.
Drains and Dressings
The decision to use drains, either Penrose, ribbed or suction
is a matter of personal preference. Drains do not prevent the
formation of large hematomas, but will reduce small collections
of blood or serum. The application of the dressing is done after
through washing of the hair with shampoo and conditioner to
reduce tangling and improve cleanliness. A Kerlix is moistened
with saline and folded into a U shaped bandage to cover the
ears, neck and ears. A second dry Kerlix is used loosely and
circumferentially. And finally four-inch Coban is loosely applied
to hold the bandages in place. The dressing is not a pressure
After surgery overnight assistance is recommended to monitor
the patient and to assist with patient care. These recommendations
may be helpful:
Elevate the head of the bed at all times.
Ice packs or frozen peas in zip lock bags to the eyes for the
first 48 hours.
Anti-nausea medication at the first indication of any nausea.
Antibiotics are routinely used for five days postop.
Bandage removal on the first postoperative day with drain removal
and cleaning of all incisions and eyelashes with saline. Careful
inspection of the wound is done at this time. Oozing wounds
can be coated with a topical antibiotic.
Keep the neck at either extended or neutral. Neck flexion places
increased tension on the postauricular flap.
Pain control and sleep medications with appropriate medications
are given to improve comfort and reduce blood pressure.
The hair should be washed on the first postoperative day and
every day afterward.
No makeup should be applied until one day after the sutures
have been removed.
Remove sutures on the fifth to the seventh day postoperatively.
Several anchor sutures may be left for support.
No strenuous activity for the first two weeks. Active sports
are not permitted for six weeks.
Patients are encouraged to walk and be up and about as much
Figure 14 Pre and postop photos
Figure 15 Pre and postop photos
Figure 16 Pre and postop photos
Every surgical procedure has associated complications. The most
frequent problems include hematoma, skin slough, nerve injuries,
hair loss, scars, pigmentation, pain and asymmetry. Hematoma
usually occurs in the first 12 hours and may be a small collection
of blood that may be watched or a large collection of blood
that may threaten the skin flap survival. Large or medium hematomas
should be treated immediately, the blood removed and bleeding
site searched for and coagulated. The cause of postoperative
bleeding is multifactorial. The bleeding may be caused from
anti-inflammatory agents, vitamin E, aspirin, anticoagulants,
postoperative blood pressure elevation, uncoagulated vessels,
coughing, vomiting, straining, and in males.
Nerve injuries may be the most dreaded of all complications.
The nerves may be injured by laceration, cautery, or stretch.
The buccal branches, marginal mandibular, and temporal branches
of the facial nerve may be injured. The great auricular and
spinal assessory nerve in the neck may also be exposed to injury.
Careful dissection and accurate knowledge of the anatomy are
essential. If a nerve has been transected, then microscopic
repair should be performed at the time of the surgery.
Alopecia may be a result of flap tension or direct injury by
superficial dissection or cautery. Visible scars may result
from cautery at the wound edge or tension. Loss of hair in the
scar may be treated with micrografts. Thick scars may benefit
from steroid injection and later revision if necessary. Asymmetry
and contour irregularities may be corrected after all swelling
has subsided. Hemosiderin staining causing hyperpigmentation
usually disappears in the first 12 months.
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