Endoscopic Subcutaneous and SMAS Facelift Without Preauricular Scars

Antonio de la Fuente, M.D., Ph.D., and Ana B. Santamaria, M.D., Ph.D.

Madrid, Spain

Abstract. Since the advent of endoscopic techniques for facialrejuvenation, we have seen an increasing number of patientsasking for facial improvement who refuse a conventional fullfacelift. During the last 3 years, in seeking to obtain goodresults for this group of patients with minimally invasive tech-niques, we have been using a subcutaneous approach for liftingof the mid- and lower face. This subcutaneous temporofaciallift combined with SMAS suspension, which resembles ourconventional approach of rhytidectomy but avoids preauricularscars, is an excellent approach for selected cases.

Key words: Rhytidectomy—Rhytidoplasty—Endoscopiclift—Facelift

Facelift techniques were first described at the beginningof this century. At that time the techniques usually in-cluded incisions from the temporal scalp, around the ear,and in the occipital scalp. The face was undermined in avariable extension, excised, and sutured around the inci-sion.

In 1974 Skoog introduced superficial musculoaponeu-rotic system (SMAS) suspensory techniques, advancingthe skin and SMAS as a single unit to provide a stronger,longer-lasting pull (deep-layer suspensory technique)[33]. In 1976, Mitz and Peyronie published the first de-tailed anatomic description of the SMAS (which hadbeen alluded to previously inGray’s Textbook ofAnatomyand vaguely described by French and Germanauthors as early as the turn of the century) [26].

In the late 1970s and 1980s, efforts were further fo-cused on improvement of the midface, described by Ow-sley [27,28,32].

In 1980 Tessier described a procedure that he termed

the “orthomorphic subperiosteal facelift,” which con-sisted of subperiosteal dissection of the superior and lat-eral orbital rim to allow elevation of the soft tissue andeyebrow as an aesthetic extension of this practice in cra-niofacial reconstruction [36]. Psillakis et al. expandedthis concept to the upper and midface for correction ofthe aging face [30].

In 1990, Hamra [18,19] described the deep-plane face-lift, which he developed from a pure sub-SMAS Skoogtechnique. Most previously described techniques formidfacial rejuvenation required extensive peripheral tocentral dissection in the subcutaneous, sub-SMAS or“deep plane,” and subperiosteal plane [4,11–13,16,18,20,29,31,34,35].

Facial rejuvenation, especially upper and midface, hasbenefited from the introduction of endoscopic techniquesin plastic surgery. These new techniques avoid extensiveincisions and allow better and proper access to distantstructures under magnification. Since 1992, due to betteroptical visualization, different authors [1,3,7,15,21,22]have performed initial dissections of the endoscopicallyassisted forehead–brow lift at the subperiosteal level.Since 1993 we have employed endoscopic techniques forrejuvenation of the forehead and midface. For the fore-head (Figs. 1–4), we have switched completely to anendoscopic approach. The main advantages of this tech-nique, apart from being minimally invasive, are the pres-ervation of consciousness and less scarring. It also hasless morbidity and a shorter convalescence period. Thegreater range of acceptance by patients makes this tech-nique a good complement to conventional facelift. Theindications are the same as those for a conventional lift:ptosis of the brows, wrinkles of the forehead, and glabe-lar lines. The only contraindication we find is for patientswith a high forehead who desire a narrowing of it. Forthese cases we favor a pretriquial forehead lift [6,8–10].

Rejuvenation of the midface remains an essential cor-nerstone for improvement of the aging face. The specificanatomic changes that occur with midfacial aging in-

Correspondence to Dr. Antonio de la Fuente, Paseo de la Ha-bana 72—Bajo, Madrid 28036, Spain

Aesth. Plast. Surg. 23:119–124, 1999

© 1999 Springer-Verlag New York Inc.

clude weakening of the retaining ligaments of the cheek,with gradual vertical descent of the malar soft tissue [17].The four most important features of midfacial aging in-clude gradual ptosis of the cheek skin below the inferiororbital rim with descent of the attenuated lower eyelidskin, creating a skeletonized appearance; descent of themalar fat pad with loss of malar prominence; deepeningof the tear trough; and exaggeration of the nasolabialfold. In general, these changes occur progressively.

The indications for endoscopically assisted subperios-teal midface lift are ptosis of the midface (malar flatness)and a pronounced nasolabial fold, especially in young ormiddle-aged patients without significant skin excess.

However, in our limited experience, after this procedurewe systematically found persistent edema around the or-bitomalar area, which in some cases took 3 months oreven longer to resolve. This made us reluctant to use thissubperiosteal approach on a routine basis [9]. We stillfound a good indication for this subperiosteal approachin some cases with marked ptosis of the central midface,medial to the zygomatic major muscle, although sometechnical improvements must be taken into consider-ation. Omission of the subciliar incision and, probablyeven better, use of the sub-SMAS endoscopic approachdescribed recently by Isse [5,22,23] will avoid theseproblems.

Fig. 1. The temporal incision used in these cases forendoscopic forehead lift is extended about 3 cm toward thehelical radix for endoscopic subcutaneous temporofacial lift.Observe the detail of the incision. The dissector is introducedunder the temporoparietalis fascia for endoscopic foreheadlift. A subcutaneous plane, superficial to this fascia, is usedfor endoscopic temporofacial lift.Fig. 2. The dissection, which in this case is extended to themandibular border of the jaw, is carried out with Metembaumscissors.Fig. 3. SMAS suspension(A, B).Fig. 4. Suspension of the cutaneous tissue of the face towardthe temporal area.

120 Endoscopic Subcutaneous and SMAS Facelift

In 1992 Fuente del Campo described a subperiostealrhytidectomy to achieve restoration of soft tissue withavoidance of preauricular scars [14].

Current concepts of midface rejuvenation have permit-ted us to initiate, since 1994, endoscopic techniques torejuvenate the face through small incisions, avoiding pre-auricular scars, prolonged postoperative edema of theperiorbital area, and delayed postoperative recovery(Figs. 5 and 6). We favor the same dissection plane thatwe use for conventional facelift. So for young or middle-aged patients with moderate skin flaccidity or patientswho do not want a conventional procedure or preauricu-lar scars, we use an endoscopic subcutaneous approach,through an incision located in the temporal area, in thismore superficial and conventional plane. When the deeptissues require correction we can also treat the SMASwith an endoscopically assisted technique. This subcuta-

neous and SMAS approach also resembles our conven-tional approach to rhytidectomy in facial rejuvenation.

Technique

Surgery is done under iv sedation and local anesthesia inmost cases. All patients are administered 1% lidocainewith epinephrine, 1:300,000, along the proposed inci-sions lines and the dissection plane.

In most of cases we combine this with a subperiostealendoscopic forehead lift. In these cases the subcutaneoustemporofacial lift is done through the same temporal in-cision used for the forehead, which is extended about 3cm toward the helical radix. When the temporofacial liftis an isolated procedure we use a 4- to 5-cm incision inthe temporal area, about 3–4 cm behind the hairline.

Fig. 5. Preoperative(A, C) and 1 yearpostoperative(B, D) views of a47-year-old patient after subperiostealendoscopic forehead and subcutaneoustemporofacial lift with lateralsmasectomy and blepharoplasty. Observethe new position of the brow–upper lidcomplex, with improvement of the browasymmetry, and the natural fullness ofthe cheek and malar area.

121A. de la Fuente and A.B. Santamaria

From this incision we do a subcutaneous dissectionjust superficial to the superficial temporal fascia or fasciatemporoparietalis instead of the subtemporoparietal dis-section used for subperiosteal forehead lift (Fig. 1). Thissuperficial dissection can be extended, depending on thecase, to the mandibular border of the jaw and is carriedout with Metzembaum scissors, partly blindly and partlywith endoscopic assistance (Fig. 2). After doing a carefulhemostasia with the aid of the endoscope, we grasp theSMAS with forceps to evaluate the degree of laxity andhow much we need to elevate or reset to do a plication ora lateral smasectomy according to Baker’s technique [2](Figs. 3A and B). In this case a strip of SMAS is resectedand we sew the edges of the SMAS together with thehelp of a long Reverdin-type needle and 3/0 Vicryl. Thecutaneous tissue of the face is redraped and suspendedtoward the temporal area, where a small triangle of scalp

is removed (Fig. 4). The cutaneous suspension isachieved by suturing the subcutaneous tissue of the in-ferior skin flap to the temporal fascia with 2/0 Vicrylsutures. We close the incision with staples or stitches.We tape the undermined area of the face to maintain theflap in position and to diminish the swelling during theinitial postoperative period.

Discussion

Endoscopic techniques for facial rejuvenation are ofgreat value and represent an important contribution to thetreatment of the forehead and face. At present we do notconsider the neck a good area for application of the en-doscopic approach, except in very select cases. On theother hand, the initial opposition of many patients to a

Fig. 6. Preoperative frontal(A) andoblique (C) views of a 50-year-oldpatient. One year postoperative views(B, D) after lower blepharoplasty andcombined subperiosteal endoscopicforehead lift and subcutaneoustemporofacial lift. Note the improvementin the upper two-thirds of the face.

122 Endoscopic Subcutaneous and SMAS Facelift

coronal incision to carry out a forehead lift or the lesser,but also common, opposition to preauricular scars hasmade the endoscopic forehead or face lift a good indi-cation for selected patients.

It is a common finding in our practice, as well as thoseof many other plastic surgeons, to have younger patientsasking for rejuvenation nowadays. These patients, whoprobably would not have considered surgery some yearsago, are now considering this possibility since they areaware that they can have good improvement with mini-mal scars, morbidity, and recuperation down time (Figs.5 and 6). Other patients, although they would be goodcandidates for conventional facelift techniques, just donot want to get into more radical and extensive proce-dures. They can also benefit from these minimally inva-sive techniques.

The disadvantage of this technique in our hands is thefold which can result in the preauricular region in caseswith more than moderate laxity, which requires preau-ricular skin resection. Also, a careful subcutaneous dis-section is mandatory at the temporal level, to preservethe hair follicle and avoid any risk of alopecia.

Over the past few decades, the complexity and sophis-tication of facial rejuvenation techniques have increasedmarkedly, with apparently improved and longer-lastingresults. As the procedures have become more aggressive,the surgical risk, morbidity, and postoperative recoverytime have increased significantly. Patients desire the bestprocedure and results that allow them to look better andnatural with a short convalescence period. Some relevantauthors [24,25] are questioning the fact that the resultsachieved with these more aggressive facelifting proce-dures justify the increased surgical risk and recoveryperiod. We find this subcutaneous and SMAS endo-scopic-assisted lift a safe, reliable technique for rhytidec-tomy which treats the superficial and deep facial struc-tures, providing tightening of the jaws and nasolabialfolds and elevation of the malar fat pad without deepdissection. In our opinion, the results are comparable tothose obtained with deeper dissection techniques, with-out exposure of the facial nerves and muscle, prolongedfacial edema, and risk of nerve damage.

Conclusion

The subcutaneous temporofacial lift combined withSMAS suspension is a good procedure for younger pa-tients requiring facial rejuvenation surgery. Some olderpatients with moderate flaccidity or who do not want oraccept preauricular scars or more radical procedures canalso benefit from it. With the proper indications and thecorrect technique, this procedure provides very accept-able results with minimal morbidity and recuperationtime and a very high level of acceptance. We considerthis technique an excellent approach for indicated casesof facial rejuvenation.

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