Reoperative Face and Neck LiftsJacob Haiavy, MD, DDS a,b,*, Hardeep Dhaliwal, MD, DMD a

KEYWORDS

� Facelift � Necklift � Rhytidectomy � Submentoplasty � Revision � Reoperative � Secondary � SMAS

KEY POINTS

� The complexity of the revisional facelift or neck lift is directly related to the way the primary procedure was performed.

� With so many techniques available to facial cosmetic surgeons, such as subcutaneous facelift, variations of superficialmusculoaponeurotic system (SMAS) or extended SMAS procedures, lateral SMASectomy, deep plane and composite ryhti-dectomy, subperiosteal facelift, and short scar facelifts, the revisional procedure should be directed to the specificproblems that patients exhibit, such as laxity in the upper face, laxity in the neck, jowling, or deepening of the nasolabialfolds.

� Generally, it is more prudent to restore contour within the deep layer support by the elevation of the SMAS and platysmarather than by rotating skin flaps in an exaggerated manner in a cephalad direction producing a tight unnatural look.

� It is extremely important that the posterior hairline and the temporal hairline are correctly aligned at the time of closure.

Videos of fixating the postauricular skin flap, dermabrasion with a diamond fraise bur, injection of tumescent anesthesia,and elevation of the skin flap in the subcutaneous plane accompany this article at http://www.oralmaxsurgeryatlas.theclinics.com/

In the past two decades, cosmetic surgery has become morecommon and accepted. Facelift and neck lift procedures canbe routinely viewed on the Internet or television. With easyaccess to information and reality shows demonstrating successstories, there has been an increase in demand for these pro-cedures. This increase has given rise to a new generation ofpatients who have undergone a facelift or a neck lift procedureand, because of the continued effects of aging or residual signsof aging that have not been addressed in a primary procedure,request a secondary operation.

When performing a secondary facelift or neck lift, surgeonsneed to consider the effects of the primary procedure on thetissues. Despite variations in technique of performing a facelift or a neck lift, the factors that need to be considered whenperforming a secondary procedure are the same:

� Previous incision placement and resulting scars� Amount of skin laxity� Earlobe deformity� Hair pattern changes� Fat irregularities and deficiencies� Fascial laxity leading to deep nasolabial folds and jowls� Cervicomental angle obtusity

Authors have nothing to disclose.a Inland Cosmetic Surgery, 8680 Monroe Court, Suite #200, Rancho

Cucamonga, CA 91730, USAb Department of Oral and Maxillofacial Surgery, Loma Linda University

School of Dentistry, 11092 Anderson Street, Loma Linda, CA 92350, USA* Corresponding author. Inland Cosmetic Surgery, 8680 Monroe

Court, Suite #200, Rancho Cucamonga, CA 91730.E-mail address: Jhaiavy@yahoo.com

Atlas Oral Maxillofacial Surg Clin N Am 22 (2014) 91–1021061-3315/14/$ - see front matter ª 2014 Elsevier Inc. All rights reserved.http://dx.doi.org/10.1016/j.cxom.2013.11.001

� Platysmal laxity and banding� Presence of unusual rhytids� The time that has elapsed from the original surgery� Complicationassociatedwithsecondary/tertiaryprocedures

Most patients requesting secondary facelifts or neck liftshave some form of laxity and want to improve or maintain theirfacial appearance. In addition, most of the patients seekingsecondary facelifts are older in age and often have other ail-ments concomitant with aging. Therefore, the preoperativeassessment should include a thorough medical history andphysical examination. This assessment should include a historyof over-the-counter and herbal medicines, because many ofthe patients who seek a secondary facelift or neck lift takeherbal medicines with potential ill effects on surgery. Forexample, Ginkgo biloba and testosterone can potentiallyinduce hypertension.1 Many of the herbal products are bloodthinners and can affect the coagulation cascade, such asGinkgo biloba, garlic tablets, ginger, St. John’s wort, andginseng. Omega-3 fatty acids may also affect the coagulationcascade and additionally may be related to delaying acutewound healing.2 The authors recommend that patients stop allherbal preparations for at least 2 weeks before and after sur-gery. When necessary, appropriate referrals to a primary carephysician, cardiologist, or other specialist should be made toobtain a clearance and minimize risk of perioperativecomplications.

In general, the authors’ approach to a secondary procedureis the opportunistic approach and is tailored to patient needsand existing anatomy.3 Patients present with different skinthicknesses and elasticity, variable amount of subcutaneoustissue, variable amounts of laxity and thicknesses of the

oralmaxsurgeryatlas.theclinics.com

Fig. 1 (A) A 61-year-old woman shown 11 years after a primary facelift. (B) Patient shown 1 year after revisional facelift, necklift,endscopic browlift, and upper and lower blepharoplasty and full-face CO2 laser skin resurfacing.

92 Haiavy & Dhaliwal

superficial fascia, and variable amounts of scarring from pri-mary facelift or neck lift. When evaluating patients, surgeonsshould look for residual signs of aging that have not beenaddressed in the primary procedure. It is not uncommon to seea patient who has had a facelift seeking a secondary procedureand on examination most of the laxity is concentrated in theupper face and periocular region, which was not addressed inthe primary surgery (Fig. 1). During the secondary facelift, thesurgeon can and should address those areas to achieve the bestpossible result.

Generally, most patients seeking a secondary procedurehave their skin envelope tightened with the primary proce-dure; therefore, little skin needs to be removed in the sec-ondary procedure. Alternatively, their SMAS and the muscles inthe neck are commonly lax compared with the tightened skinenvelope.4,5 In recent years, the popularity of various forms ofshort scar facelifts has given rise to an increasing number ofpatients with this presentation.

Because most of the primary facelifts performed do notinvolve an extensive sub-SMAS dissection, the secondaryfacelift benefits from some form of SMAS undermining and

Fig. 2 (A) Preoperative photo with (B) markings of a 65-year-old womincision. (C) Same patient 3 months after revisional facelift and neck lifpeel. (From Haiavy J. Reoperative face and neck lifts. Oral Maxillofac

tightening. The subcutaneous layer, which is the most commonplane of dissection in a facelift, may be thinner after thetrauma of the original procedure and facial fat atrophy,6

creating a challenge in thin patients. In these cases, it may bemore prudent to perform a SMASectomy with plication ratherthan an SMAS elevation.

Incisions and scars

Incision placement during a secondary procedure is largelydictated by the incision line made during the first operation.The authors’ preference is to make a tragal margin incision or aretrotragal incision because it is easier to hide the scar and thescar heals well. In male patients, a pretragal incision may beoptimal to prevent transposing hair-bearing skin over thetragus, or laser hair removal can be performed in the area inthe future. Before making the incision, careful assessment ofthe amount of skin laxity present should be made, and, ifenough laxity is present, a preauricular incision can be con-verted to a tragal or retrotragal incision during the reoperation(Fig. 2). On closure of the flap, there should be minimal tension

an 8 years after her primary facelift demonstrating a tragal marginalt with fat transfer to lower eyelid and full-face trichloroacetic acidSurg Clin North Am 2011;23:111; with permission.)

Fig. 3 (A) A 55-year-old patient 7 years after primary facelift with pixie ear deformity. (B) Patient shown 1 year after revisional faceliftand necklift with pixie deformity correction, endscopic browlift, upper and lower blepharoplasty, and full-face CO2 laser skinresurfacing.

Reoperative Face and Neck Lifts 93

on the tragus. To minimize tension, the skin flap is suturedabove and below the tragus with 4-0 Monocryl sutures.

Earlobe deformity

Another common stigmata of facelifts is the bat ear or pixie eardeformity (Figs. 3 and 4). This deformity is a result of poor

Fig. 4 (A) Close-up view of same patient as in Fig. 3 with pixieear deformity and (B) after correction of pixie ear deformity.

incision placement and excess skin removal caudal to the earlobe during closure of the primary procedure. The closure ofthe earlobe cannot be under tension. The deeper structures ofthe jaw line and neck should be secured to a stable structure,such as the postauricular fascia or the mastoid fascia, and theskin should be closed passively around the earlobe. To correctthis deformity, surgeons should incise the earlobe to a morerounded appearance and then inset the earlobe to its properposition.7 Hanging the cheek on the earlobe during flapredraping should never be attempted. Instead, the skin flapshould be secured to the base of the ear lobe with a 3-0 Mon-ocryl or 3-0 Vicryl suture. The skin of the earlobe is then closedwith a 4-0 Monocryl suture in a running subcuticular fashionunder minimal tension (see Figs. 3 and 4).

Hair pattern changes

One of the greatest challenges with incision placement inrevisional facelift or neck lift is problems with hairline shiftingand bald spots from the primary operation.8 Another commonstigma of facelifts is distortion or the loss of sideburn andtemporal hairline. This problem can occur when the cervico-facial flap is advanced too far in the cephalad direction,causing the hairline shift. For example, transposition of thesideburn above the helical rim can leave a bald spot above theear. This problem is difficult to correct. It is occasionallypossible to rotate the temporal hairline inferiorly and partiallylower the sideburn. As is commonly the case, avoidance of thisproblem is the best course of action.

The authors prefer to make the temporal incision in thehairline at the initial procedure and leave the sideburn or 1 cmof hair-bearing skin attached at the base of the helix. Thismethod avoids improper transposition of hair in the temporalregion. If skin needs to be removed at that location, it is donein a conservative fashion, bearing in mind not to shift thetemporal hairline. Another alternative for correction of this

Fig. 5 (A) Advancement and fixation of posterior cervical skinflap ensuring hairline alignment. (B) Excision of excess skin afteraligning hairline.

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problem is to place the incision along the temporal hairline inthe secondary procedure and avoid any additional hairlineshifting at the time of flap advancement.1

In the postauricular region, there is a potential for visiblescars when the incision in the primary procedure was madealong the posterior scalp hairline. This scar can become wideand more visible when the neck tissues are suspended to thepostauricular scalp skin as opposed to the deeper scalp struc-tures. In the revisional procedure, surgeons have an opportu-nity to remove some of or the entire scar as long as enough

Fig. 6 (A) A 54-year-old woman 9 years after primary facelift with inSame patient 6 months after reoperative facelift and necklift with fat

laxity is present. It is the authors’ preference to make the newincision in the hairline cephalad to the old scar in a line that isperpendicular to the vector of pull. If the incision is made in abeveled manner and the dissection is made in a plane to avoiddamage to the hair follicles, this incision heals so well that it isalmost invisible a year later when the hairs have grown into thescar. When advancing the posterior cervical skin flap in acephalic direction, the authors place 1 or 2 deep permanentsutures (2-0 Ethibond or Neurolon [Ethicon, San Angelo, Texas])that secure the deep portion of the skin flap to the deepposterior scalp fascia and/or the periosteum (Fig. 5, Video 1).The excess skin and the old scar are then trimmed, and theincision is closed with staples passively under no tension. Careis taken to align the posterior hairline during closure (seeFig. 5, Video 1).

Fat irregularities and deficiencies

Because patients continue to age after their primary surgery,there is continued laxity of the skin and underlying tissues andfacial fat atrophy. In addition, because patients are seekingthese procedures at an early age and have minimal neck laxity,surgeons have become more aggressive with cervical and facialfat removal. This situation has led to the problem of the pa-tients presenting for a secondary procedure with an over-skeletonized neck (cobra neck deformity) and submalarhollowing. This lack of subcutaneous fat makes it difficult todisguise the fascial and platysmal irregularities that may occurduring surgical manipulation, especially on thin patients. Tocorrect this problem, in the secondary procedure, instead ofremoving fat, surgeons should attempt redraping a patient’sexisting fat from the jowls cephalically over the buccal recess.In the authors’ practice, it has been more common to performfat grafting rather than fat removal procedures during faceliftrevisions, as has been found by other investigators.9 Fatgrafting can correct the hollowing in the submalar, infraorbi-tal, and perioral regions and help efface deeper lines (Fig. 6).

ftraorbital, submalar hollowing, and tear trough defomormity. (B)transfer to infraorbital, submalar, malar, and nasolabial folds.

Reoperative Face and Neck Lifts 95

Patients need to understand that they may need multiple fatgrafting sessions to achieve optimal results. With advance-ments in stem cell research and isolation of stem cell fromadipose tissue, it may not be long before revisional surgery canbe combined with one session of stem celleenriched fatgrafting to correct these problems.

Fascial laxity

Patients presenting for a secondary facelift or neck lift usuallyhave minimal skin laxity, but more commonly they have someform of laxity in the deeper layers (SMAS and platysma muscle)that can lead to deepening of nasolabial folds, jowls, andplatysmal banding. Usually, SMAS elevation is limited duringthe primary procedure. Therefore, most patients benefit fromre-elevation and tightening of the deeper fascial layers (Figs. 7and 8).1,10

Surgeons should be cautious because scarring from previoussurgery can distort the anatomy. Fortunately, the scarringis mostly over the parotid gland, where the facial nervebranches are deep to the plane of dissection. It is alsoimportant not to carry the dissection too deep over the

Fig. 7 View of SMAS and platysma (A) after initial subcutaneous disalized. (C, D) The platysma is elevated starting inferior to the border oin sub-SMAS and subplatysmal plane until adequate release is achieved.platysma is sutured to the sternocleidomastoid (SCM) fascia.

parotid, because damage to the gland can lead to a sialocele.Once the SMAS is freed past the parotid gland, the dissectionbecomes easier in the sub-SMAS areolar plane. It is importantto understand the anatomy of the facial nerve and its rela-tionship to the SMAS and facial muscles (Fig. 9). The zygoma-ticus major and zygomaticus minor as well as orbicularis oculiand platysma muscles receive their innervations through theirdeep surface, whereas the buccinator, levator anguli oris, andmentalis muscles are innervated along their superficial sur-face.11 Therefore, when the SMAS elevation is performed, aslong as the dissection is carried out along the superficial sur-face of the facial muscles, injury to the facial nerve is notlikely. Furthermore, as discussed previously, the authors’approach is opportunistic, and the dissection is carried outmedially only to the point needed to achieve adequate releaseand correction. This approach varies with each patient. Ifextensive scarring is present to the point where the relation-ship between the superficial and deep fascial layers isobscured, a simple SMAS plication is preferable (see Fig. 8).Also, if the SMAS is found very thin and attenuated, it becomesdifficult to perform a smooth elevation of that layer because itmay tear. Therefore, a simple plication in this case may servepatients and surgeons better.

section and (B) after open liposuction the platysma is better visu-f mandible at its most posterior aspect. The dissection is continued(E, F) The flap is then sutured in a posterior superior direction; the

Fig. 8 (A) A 70-year-old woman 14 years after primary facelift. (B) Same patient 3 months after revisional facelift, necklift, and lowerblepharoplasty.

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The cervicomental angle and platysma

The cervicomental angle has been studied extensively. Forideal aesthetics, it should be approximately 90�, but a widerange of normal neck morphology exists and the angle mayvary from 105� to 120�.12,13 The angle is usually more obtusein women than in men. A low and anteriorly positioned hyoidbone also leads to a more obtuse angle. This morphology canbe camouflaged by placement of a chin implant to increasethe thyromental distance, thus giving the illusion of a moreacute cervicomental angle (Fig. 10).14 Because primary sur-geries are done at early ages, they usually involve removal ofpreplatysmal fat and tightening of cervical skin. With aging,

Fig. 9 Relationship of the facial nerve to the facial muscles.(Courtesy of Patrick J. Lynch, medical illustrator; C. Carl Jaffe,MD, cardiologist. http://creativecommons.org/licenses/by/2.5/.)

the platysma muscle becomes more attenuated and the pla-tysmal bands become more obvious. Another factor that cancontribute to cervicomental obtusity is fat accumulationunder the platysma. In a revisional surgery, it is more commonto see this condition than the accumulation of preplatysmalfat if a patient has gained significant weight. Therefore, inthe revisional facelift or neck lift, every effort should bemade to preserve the fat on the cervical skin flap, especiallyif subplatysmal fat removal is planned. The authors do notroutinely perform submental liposuction when performing arevisional neck lift, especially if an extensive platysmaplastyis planned.

The authors’ approach to the neck is through the sub-mental incision centrally and the postauricular incisionlaterally (Fig. 11). Once adequately exposed, the amount ofplatysmal laxity is evaluated, and, if necessary, excess muscleand fat are clamped and removed centrally in a conservativefashion to prevent undue tension on the suture plication. Thesubplatysmal fat is then exposed by elevation of the medialborders of the platysma from the mentum to the level of thecricoid cartilage. The excess fat is then removed under directvision with the Bovie cautery and scissors. Careful hemostasismust be obtained. This fat contouring has to be precise, andcare should be taken to avoid over-resection of fat in thesubmental region. This over-resection can lead to a hollowedout submental appearance, or cobra neck deformity, that isdifficult to correct. A greater amount of fat can be removedat the level of the hyoid, where it helps to deepen thecervicomental angle. In addition, releasing the muscle later-ally by performing a myotomy either at the level of the hyoidor just caudal to the last muscle plication suture relievessome of the tension along the platysmal plication and allowsthe platysma to shift superiorly, creating a deeper cervico-mental angle (Fig. 12). This back cut or myotomy of theplatysma is parallel to the inferior border of the mandible

Fig. 11 Sequential steps for submentoplasty, with open liposuction to define platysma, then central playstmal resection and subsequentplicaton.

Fig. 10 (A) A 73-year-old man, 12 years after primary facelift, demonstrating recurrent facial laxity and retrogenia. (B) Same patient3 months after revisional neck lift and cleft chin implant placement.

Reoperative Face and Neck Lifts 97

Fig. 12 Platysmal plication and lateral myotomy. (From SykesJM. Rejuvenation of the aging neck. Facial Plast Surg 2001;17:103;Thieme-connect; with permission.)

98 Haiavy & Dhaliwal

and away from the submandibular gland, facial artery, facialvein, and the facial nerve. After adequate mobilization ofthe platysma, the edges of the muscle are grasped andoverlapped in the midline. Platysmal plication is then per-formed with interrupted 3-0 Vicryl or 3-0 silk sutures from thementum to at least the level of the hyoid bone. The authorsoften continue this plication lower to the level of the thyroidcartilage, especially on a long-necked person with long bands.In thin patients with little subcutaneous fat, it is important tobury the knots and be careful to create a smooth contourbecause the anatomy created with the muscle plication isimmediately visible under the skin with little padding. Thegoal of muscle plication is to produce an even, smooth pla-tysma contour that tightly adheres to the underlying struc-tures, producing a proper framework for redraping of thecervical skin.

On occasion, patients presenting for secondary facelift orneck lift have bulging of the submandibular gland. This pre-sentation can be secondary to overaggressive liposuctionduring the primary procedure or just ptosis of the gland withattenuation of the deep fascia and gland capsule. Some pa-tients may accept this side effect of the primary procedure asan explanation of normal anatomy. During the secondaryprocedure, surgeons can address the ptotic gland by eitherattempting a sling suture, such as the Giampapa suture fromthe submental region to each mastoid fascia, or performingpartial resection of the submandibular gland. The gland can beapproached through the subplatysmal dissection, whereby thecervical fascia is carefully penetrated over the bulge of thegland. The most inferior and anterior portion of the gland isthen gently grasped, and the excessive portion of the gland isremoved. This procedure has to be done with extreme careand under excellent visualization because branches of thefacial artery and vein and the mandibular branch of the facial

nerve are close by and have to be preserved. This procedureshould be reserved for experienced surgeons familiar with theanatomy.

Presence of unusual rhytids

Facial rhytids are not removed by facelifts or neck lifts,whether it is primary or revisional surgery. The rhytids areimproved and redraped. Regarding nasolabial folds, they areoften referred to as the “undefeated nasolabial folds” and theytoo can be improved but not removed.

Occasionally, patients present for reoperation with unnat-ural-looking rhytids, which occur as a result of an exaggeratedrotation of the cervicofacial flap, causing the rhytids to run inan upward direction. This condition is compounded by, withaging, patients losing some of the skin elasticity and havingmore actinic damage because of continued sun exposure,leading to inelastic poor-quality skin with keratotic changesand hyperpigmentation. Therefore, at the secondary proce-dure, surgeons should be aware of the direction of flap rotationto not exaggerate the abnormal rhytids. Furthermore, laserskin resurfacing and/or chemical peels are useful adjuncts tothe secondary procedure; these techniques can correct theactinic changes and improve some of the fine lines and rhytids.When combining revisional surgery with laser resurfacing orchemical peeling, the skin dissection is kept to the minimumand the lift must rely mostly on the rotation of the deepermusculofascial structure. This method works well becausemost of the patients presenting for the secondary procedurehave little skin laxity. On smokers, is advisable to do shorterskin flaps and rely mostly on the SMAS and platysma dissection.The skin flap in reoperations should be more resistant tovascular compromise, especially because it was delayed duringthe primary procedure.10

In addition, some patients develop significant perioral rhy-tids (in particular, vertical upper lip rhytids) that are difficultto correct during a secondary facelift. It is the authors’ pref-erence to perform CO2 laser skin resurfacing with concurrentdermabrasion on these patients (Fig. 13, Video 2). In somecases, volumizing the upper lip and using neurotoxins can alsohelp efface these lines. Using multimodality skin resurfacing,volumizing, and neurotoxin treatments within this area isusually required to improve such deformities.15,16

Face tuck

A common question presented by patients is, “How long willmy facelift last?” A recent article tried to answer this questionfor a single surgeon.17 Studies have shown the average dura-tion between primary and secondary procedures is 9 years,which is similar for the duration between secondary and ter-tiary procedures.9 The authors’ standard answer is, “Thechanges that one will make to your face are permanent butyou will continue to age.” Patients who want to maintain theirlifted appearance are better served with a face tuck within thefirst 2 to 3 years after the primary procedure (Figs. 14 and 15).

In that period, the scar tissue is still fairly resilient andthe pull in the periauricular area can be easily transmitted tothe jowl and neck. When the wait for the secondary procedureis longer, a combination of skin elevation, SMAS dissection,and plication as well as platysmal manipulation followed bycareful skin redraping often leads to considerable improve-ment and a satisfied patient. The authors caution against

Fig. 13 (A) A 63-year-old woman 10 years after primary facelift, demonstrating perioral rhytids. (B) Same patient 3 months afterfull-face CO2 laser skin resurfacing with concurrent perioral dermabrasion.

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performing secondary face or neck lifts prior to 1 year fromthe primary procedure. Early operation can be challenging dueto scarring and difficult fibrous dissection as well as excessivebleeding.

Complications with secondary/tertiaryprocedures

Secondary and tertiary procedures have been thought associ-ated with higher rates of complication, in particular, facialnerve injury.9 This is normally assumed because previous

procedures may alter the anatomy, or scarring may makeplanes of dissection less distinct.18 Other investigators haveshown that, in general, the complication rates of primary andsecondary procedures are similar but may vary depending onhow extensively the deep plane dissection is performed.9 Theauthors have found similar rates of complications with primaryand secondary procedures. The authors prefer to use tumes-cent infiltration in the subcutaneous plane to help by reducingbleeding and making the dissection plane easier to identify,thus lowering the rates of complication (Video 3).19 The au-thors also use a liposuction cannula, with or without suction, tohelp identify the dissection plan by way of pretunneling the

Fig. 14 (A) A 70-year-old woman complaining of sagging in the face, jowl and neck (first row) prior to primary facelift and 3 months(second row) and 2 years (third row) after primary facelift and neck lift showing recurrent facial laxity. (B) Same patient 3 months afterfacial tuck and endoscopic brow lift.

100 Haiavy & Dhaliwal

dissection plane (see Video 3). The authors also prefer the useof electrocautery to perform the sub-SMAS dissection withconstant visualization of the face for any facial nerve activity(Video 4). If any facial movement is seen, the dissection isredirected or stopped.

Furthermore, the authors are proactive in attempting tolimit postoperative hematoma and seroma formation. Theauthors administer 0.1 mg of clonidine (Catapres, BoehringerIngelheim Pharmaceuticals, Ingelheim am Rhein, Germany)by mouth to all patients who are normotensive or hyper-tensive prior to surgery. On occasion, some patients areadministered 0.2 mg of clonidine by mouth preoperatively if

the blood pressure permits. In patients with continued orrebound hypertension postoperatively, clonidine may becontinued for 1 to 2 days postoperatively.

In addition, all patients with a history of hypertension have adrain placed in the neck for 1 to 7 days postoperatively. Theremainder of patients has a 14-gauge angiocatheter or miniventplaced in the neck exiting the midline neck with the catheterportion placed under the flap.20 These minivents are usuallykept in for 24 to 48 hours only and allow for drainage of bloodand fluid during the early postoperative period. In the authors’experience, these small maneuvers in the perioperative periodhave reduced postoperative complication significantly.

Fig. 15 (A) A 67-year-old woman complaining of facial laxity and jowling (first row) prior to primary facelift and 3 months (second row)and 2 years (third row) after primary facelift and neck lift showing recurrent facial laxity. (B) Same patient 3 months after facial tuck andendoscopic brow lift.

Reoperative Face and Neck Lifts 101

Summary

The complexity of the revisional facelift or neck lift is directlyrelated to the way the primary procedure was performed. Withso many techniques available to facial cosmetic surgeons, suchas subcutaneous facelift,21 variations of SMAS or extendedSMAS procedures,11,22,23 lateral SMASectomy,24 deep plane andcomposite ryhtidectomy,25,26 subperiosteal facelift,27,28 andshort scar facelifts,29 the revisional procedure should bedirected to the specific problems that patients exhibit, such aslaxity in the upper face, laxity in the neck, jowling, or deep-ening of the nasolabial folds. In general, it is more prudent torestore contour within the deep layer support by the elevationof the SMAS and platysma rather than by rotating skin flaps inan exaggerated manner in a cephalad direction producing atight unnatural look. In addition, it is extremely important that

the posterior hairline and the temporal hairline are correctlyaligned at the time of closure.

Supplementary data

Supplementary data related to this article can be found athttp://dx.doi.org/10.1016/j.cxom.2013.11.001.

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