The SACS, ESP and Prehairline-Terrace Lifting

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44

are focussed on the following requirements of a facelift procedure (Table 44.1):

– Volume displacement of skin and underlying structures by gravitation should be reversed by repositioning, redraping and evenly redistributing sagging tissues without ending up with a tight- looking face.

– The nasolabial fold should be flattened, the jowls should disappear in favor of a clean jawline and a regular cervicomental angle.

– The sunken malar fat pad should be repositioned higher up.

– The neck should be rejuvenated, no submental li- pomas (double chin) and no platysma bands should be visible any more.

– The result should be natural-looking, stigmata of the so-called facelifted or surgical look should be avoided:

– No displacement or recession of the temporal hairline, no tight look with diagonal tension on the cheeks and no distortion of the earlobes or flattening of the tragus should occur.

44.1 Introduction

The author’s concept and strategy in facial rejuvenation can be summarized as follows. Facial contouring means an even distribution of volume. Tightening has been replaced by repositioning, distributing, balancing, reducing and/or replacing volumes according to the requirements of each facial area. The direction of repositioning is mainly vertical:

1. Endoforehead to raise the brows and the upper third of the face.

2. Vertical subperiosteal midface advancement to elevate the cheek mound.

3. Balancing the volumes of the lower face, jawline and neck by undermining in the deep subcutaneous (supra-superficial musculo-aponeurotic system, supra-SMAS) level, flap advancement in a vertical direction through the prehairline periauricular incision (the postauricular flap is a rotation flap), liposuction in the submental and submandibular area to mold the cervicomental angle and reduce the jowls, and fatgrafting for replacing volumes perioral and nasolabial.

Flap undermining of the SMAS layer is avoided in favor of plications or SMAS-ectomies.

The difficult neck with prominent platysma bands can be approached by the Feldman platysmaplasty with a corsetlike suturing in the midline [7].

All these procedures can be combined and will in- teract to reestablish facial harmony in contours, volumes and skin surface. Ancillary procedures such as laser skin resurfacing, dermabrasion and chemical peels will contribute to improve the skin texture.

The primary purpose of a classic face–neck contouring is to reestablish a clean jawline with repositioning of sagging volumes. Jowling is the main con- cern of most patients. To get rid of the Hamsterbacken – the German expression for “jowls” – and the sunken skin of the neck and below the chin, with a natural result without looking tight or pulled, is the most fre- quent motivation for undergoing a facelift procedure.

The numerous methods described in the past 20 years

The SACS, ESP and Prehairline-Terrace Lifting

Christoph Wolfensberger

Table 44.1. Operative techniques of cervicofacial rhytidecto- mies rebalancing volumes

Reduction:

Submandibular Submental Jowls (partially) Reposition:

Malar Midcheek Jowls (partially) Augmentation:

Perioral LipsNasolabial (fold) Chin (“marionette fold”) Infraorbital (“tear trough”)

Liposuction

“ESP”/SACS lifting Subperiostal vertical midface advancement

Lipostructure Fatgrafting

ESP extended supraplatysmal plane, SACS superficial adipo- cutaneous system

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Beauty does not mean tightness but even distribution of facial contours and volumes; therefore the surgeon has to correct the anatomical structures responsible for that even surface: the skin and the underlying fat, the subcutaneous tissue and the various fat pads of the face.

Gently mobilizing and redraping these anatomical structures instead of pulling on the skin became the concept of modern volumetric rhytidectomy techniques. Reconstructing facial harmony by repositioning and redistribution of volumes is the main chal- lenge of today’s facial rejuvenation surgery.

What does “volume” mean in facial anatomy? Its primary aspect is the bony support, namely, the malar eminence, the mandibular arch and the chin.

Volume of the overlaying soft tissues is provided by the fatty tissue, the subcutaneous fat layer distributed all over the face and neck area, and the different “con- centrations” of fat, namely, the malar fat pad, the midfacial fat with the nasolabial pouch and the buccal (Bichat’s) fat. Laxity, downwards sliding and dysbal- ance of distribution with aging leads to jowling, thickening above the nasolabial fold and double-chin for- mation.

In addition to that, facial harmony is disturbed by loss of volume in the perioral and periorbital region.

Faces look unattractive, tired and negative not pri- marily because of wrinkles – that is a widespread er- ror – but because of losing the balance of facial volumes.

44.2 Volumetric Maneuvers Below the Jawline:

Fine Tunneling and Superficial Liposuction

In the late 30s or early 40s with the beginning of the early stage of jowling, a wide soft-tissue undermining is not yet required. A detachment in the deep subcutaneous layer limited to the midcheeck and the lateral third of the neck combined with a submandibular and submental superficial liposuction [9] will provide a regular clean jawline with flattening down of the jowls (Figs. 44.1).

The surgery is performed under general anesthesia with intravenous Propofol, the headrest allowing a smooth turning of the head to the left and the right side. The tumescence is performed with the following liquid: 250 ml Ringer’s lactate, 10 ml 1% Xylocaine, 0.5 mg adrenaline, 60–80 ml each side infiltrated to the cheek/submandibular/submental area before liposuction (Fig. 44.2).

The periauricular incision and partial undermining and infiltration of the cheek–neck area proceeds with the introduction of a 2 mm liposuction cannula for in the submental and submandibular region (Fig. 44.3). The fine tunneling of the neck below the jawline and of the submental area has a contouring effect in addition to the required reduction of volume (Fig. 44.4).

Fig. 44.1. A 42-year-old patient with unpleasant lower face jowling compared with a juvenile upper face. Result 3 weeks after face–neck contouring from a periauricular access up to the midcheek and the lateral third of the neck with undermining in the subcutaneous layer combined with a superficial liposuction of the submandibular and submental area. A perioral microfatgrafting including the nasolabial, upper lip, angle of the mouth and vermilion area has completed the facial rejuvenation

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Fig. 44.2. Infiltration solution for facial liposuction

Fig. 44.3. The periauricular incision and partial undermining and infiltration of the cheek–neck area proceeds with the introduc- tion of a 2 mm cannula for liposuction in the submental and submandibular region

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44.3 Volumetric Maneuvers in the More Advanced Stage of Midfacial Aging: Superficial Adipo-cutaneous System, Extended Supraplatysmal Plane Liftings

In the more advanced stage of aging, a more extended undermining is necessary for repositioning sagging skin and volumes. A deeper plane of detachment avoiding vascular damage compromising the blood circulation of the flap is advisable.

There have been many discussions about which is the anatomically correct plane in the past.

Hamra, a pioneer of the deep plane facelifting, has brought fundamental inspiration to anatomical thinking and reflection about facial rejuvenation.

In Hamra’s deep plane rhytidectomy [10] the plane of undermining is on top of the orbicularis and the zygomaticus major and minor muscles. In the “composite rhytidectomy” [11] the author additionally includes the orbicularis oculi muscle and the SMAS/

platysma layer of the cheek above the jawline (sub- SMAS) into the underminded flap. The concept of this technique is the belief that there is a similar amount of aging in all soft-tissue layers of the face, including fibromuscular tissues, the fat pads, the subcutaneous fat and the skin. therefore, all these layers have to be elevated en bloc with the composite flap.

Hamra’s analysis of aging in relation to facial anatomy says that “the ptotic cheek fat becomes the nasolabial fold …. and the ptotic platysma muscle of the face becomes the broken jawline or jowling of the lower face” [11].

A different standpoint is taken by Trepsat [16], who says that the main reason for facial aging is a progressive ptosis of the skin and the subcutaneous fat layer including the facial fat pads, and the thickening/

accumulation of submental and submandibular fat layer, much more than alterations of the fibromuscular tissue. Jowls belong to the earliest signs of aging owing to a sagging and accumulation of subcutaneous fat in the lower cheek area on both sides of the chin, lateral to the osteocutaneous mandibular ligaments. In the majority of faces there is an important difference in laxity between the skin fat layer and the fibromuscular tissue (SMAS/platysma).

These planes have to be separated from each other, says Trepsat, to provide the possibility of more ex- tensive repositioning the superficial plane (mainly responsible for aging) compared with the SMAS/platysma system.

Analysis of the aging process proves that sliding downwards and laxity of the skin fat layer cause the signs of aging much more than alterations of the fibromuscular tissue [12, 16].

Therefore, the correct level of undermining is the deep subcutaneous plane just on top of the SMAS, leaving all the fat on the flap.

This type of facelift is called lifting of the superficial adipo-cutaneous system (SACS lifting). This level of undermining gives direct access to the subcutaneous fat and its accumulations as well as the pads (malar, buccal, jowls) for contouring – it is a true volumetric access to the midfacial and jawline structures.

Corresponding to that concept ,the following experience is described by Ellenbogen [6]:

It has been our observation that facial aging is pri- marily caused by the loss of facial fat volume and the descent of upper facial fat below the mandibular border. Many techniques have attempted to address this issue by lifting or repositioning the SMAS and other layers to restore volume to the face. However, in our experience, this often pro- duces insufficient volume correction and a pulled look, which may only be correctible by subsequent fat restoration.

Therefore, procedures for restoring, repositioning and – in some areas – replacing volumes instead of tightening will provide the most “physiological” ther- apy of facial aging.

Hoefflin [12] with his name extended supraplatysmal plane (ESP) facelift takes a similar standpoint saying that “the ptosis of the subcutaneous fat and

Fig. 44.4. The fine tunneling of the neck below the jawline and of the submental area has a contouring effect in addition to the required reduction of volume

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skin is the predominant cause of facial aging” and that “the nasolabial fold is due to progressive thickening and ptosis of the lower portion of the cheek fat and skin, but not to appreciable changes in the muscle plane (SMAS).” Therefore, he prefers a dissection plane above and not below the platysma aponeurosis/

SMAS, to get more efficiency in correcting signs of aging, namely, the ptosis of skin and fatty tissue. The supraplatysmal plane is a dissection that leads imme- diately on top of the platysma muscle/SMAS layer with all facial fat superficial to the platysma and the SMAS kept on the skin flap, where it can be mobilized and contoured.

The extent to the corner of the mouth includes a more complete ligamentous release.

44.3.1

Operative Technique

The cheek undermining is performed superficial to the parotid gland above the parotid fascia and the SMAS layer. The dissection is continued above the orbicularis oculi muscle after visualization of the edge of the orbicularis oculi and the undermining goes over the zygomaticus major and minor muscle.

The front dissection is carried on to the level of the nasolabial fold, to the modiolus and under the jowl, where the mandibular ligament is released

The plane of dissection is under the adipocutaneous layer but above the SMAS layer, leaving all fat on the flap, providing good access to all fat that has to be repositioned, molded and recontoured from inside.

The postauricular undermining leads to the ante- rior border of the sternocleidomastoid muscle. After the platysma muscle has been identified, the dissection can extend across the neck. Special attention has to be paid to the greater auricular nerve.

The cervicofacial soft tissue is dissected in the subadipose layer over the SMAS. The platysma fibers on the cheek are identified and the dissection is continued on to the buccal commissure and down to the release of the mandibular ligament. In the zygomatico- malar area is not necessary to change planes. The detachment is still subadipose and in the direction of the nasolabial pouch the fat layer, always remaining on the flap, thickens. The zygomatic muscles stay below the dissection plane. The total liberation of the adipocutaneous layer from the fibromuscular plane and its repositioning will provide 80% of the result.

The efficiency of eventual actions on the deep layers has to be checked and carried out as plications or SMAS-ectomies according to the requirements in each individual case.

From this access the platysma can be put under tension laterally or, in cases of prominent platysmal bands, a Feldman corset platysmaplasty [6] can be carried out with plication of the platysma in the midline; therefore, a submental incision is necessary.

If the nasolabial pouch is very dense and very thick, it is advisable to incise it parallel to the nasolabial fold and to spread the opened pouch perpendicular to its long axis (Fig. 44.5).

Fig. 44.5. Spreading of the nasolabial pouch perpendicular to its long axis

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44.3.2 Anatomy

The superficial plane just under the skin with a thin layer on facial fat of the skin flap does not correspond to a proper anatomical plane. Too many vessels especially of the subdermal plexus are divided.

Anatomically the subadipose dissection encounters and damages far fewer of the important vascular elements and separates the two anatomical leaflets without injuring either of them (Fig. 44.6).

A Trepsat dissector in different sizes (Fig. 44.7a, b) may be helpful to perform a wide undermining with spreading movements, blunt-tipped scissors allowing atraumatic separation of the various anatomical layers. The deep plane undermining is extended to the nasolabial fold, the modiolus and the mandibular osteocutaneous attachments (Fig. 447c, d). All the fat remains on the flap (Fig. 44.7e).

The deepening of the nasolabial fold with aging is due to progressive thickening and ptosis of the lower portion of the cheek fat and skin but not to any re- markable change in the fibromuscular plane (SMAS) [12, 16].

Attention must be paid to a localized thickening of the following areas of fat pads: submental, buccal, nasolabial (midcheek) and malar. The deep subcutane-

ous undermining over the SMAS/platysma layer allows the surgeon the directly address these fat collections for contouring. In addition to that, the deep subcutaneous approach (supra-SMAS) provides a complete release of the osteocutaneous ligaments described by Furnas [8] for better mobilization and even distribution of tissues: malar (McGregor’s patch), parotid, masseteric, infra-inferior-distal-zygomatic, mandibular (Fig. 44.8).

The advantages of the plane of dissection described (SACS, ESP) are:

1. Direct access to the fatty tissue and its accumulations (jowls, malar fat pad, nasolabial pouch) for mobilizing and contouring.

2. Safe wide undermining in a relatively avascular plane with no damage to the skin blood supply.

3. Even distribution of volumes by release of the osteocutaneous ligaments.

4. The SMAS/platysma plane can be addressed separately.

The more advanced the situation of jowling and sagging of the facial skin and fat, the more extended epi- fascial undermining is necessary to provide access to all zones of drooping, accumulated fat and the release of osteocutaneous ligaments (Figs. 44.9, 44.10).

Fig. 44.6. A subcutaneous dissection would injure a large number of perforating vessels and lymphatics.

A subadipose dissection encounters far fewer vascular elements, and separates the two anatomical leaflets, without injuring either of them

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Fig. 44.7. a, b Trepsat dissecting instrument for spreading movements. c, d Wide undermining in the deep plane between fat and fibromuscular tissue (superficial adipo-cutaneous system, SACS, lifting). e, f All the fat is kept on the flap

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Fig. 44.8. The osteocutaneous ligaments of the face: malar, parotid, masseteric, infra-inferior-distal zygomatic, mandibular, and their release (visible in the result on the right)

Fig. 44.9. a A 62-year-old female patient with very prominent jowls, sagging of the cheeks and thickening of the fat pad above the nasolabial fold, “rectangular”

face in the front view. b To reestablish a clean oval jawline a supra-superficial musculo-aponeurotic system cervicofacial rhytidectomy with contouring of the subcutaneous fat, namely, in the jowl area, was performed with a wide undermining of the lateral cheek and jawline zone, releasing the osteocutaneous ligaments

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44.4 Skin Incisions: the Prehairline Terrace Lifting (Avoiding Hairloss and Hairline Displacement)

44.4.1

Plane of Undermining and Incision Lines

When Performing a face–neck rhytidectomy, the first question will be which is the best plane to operate with the purpose of redistributing the various volumes and which will be the incision lines to get access to the tissues responsible for the volume displacement and alteration.

Avoiding hairline distortion is a must in modern facial rejuvenation surgery. A facial aesthetic surgery creating a juvenile contour of the jawline but leaving a zone of baldness in the temporal hair is conterpro- ductive!

Cervicofacial rhytidectomy with a wide undermining and mobilizing the midfacial and cervical skin/fat

layer creates a significant amount of skin to be resect- ed. There is a direct coherence between laxity (or skin excess) and the necessity of skin excision [3]. The periauricular incision lines – and the scars – should be kept as short as possible [1, 15] but must have an extent allowing sufficient skin removal in advanced stages of facial aging [3, 17].

Wide mobilization with osteocutaneous ligament release and the good vascularity of the flap in ESP or SACS lifting techniques allows a large advancement with significant skin excess to be removed. therefore, the skin incision lines have to be placed in front of the temporal sideburn, if hairline recession is to be avoided. This is of further importance in secondary rhytidectomy procedures with a high incidence of hairloss from a primary facelift 10 or 20 years ago.

The hairline should be respected as an aesthetic unit of the face. Fullness of the hairline is a sign of youth (Fig. 44.11); a receding hairline with baldness of the sideburn area–as pointed out by Connell [5] – is a sign of aging and should not be “produced” by using

Fig. 44.10. The extent of undermining

Fig. 44.11. The fronto-temporo-cervical hairline is describing a curved line in the shape of a “triple S”

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the traditional incisions inside of the temporal hair removing hair-bearing skin! (Fig. 44.12). The incision is performed with a beveled blade 2–3 mm inside the hairline in a way that through the transected hair follicles a small zone of new hair can grow through the scar in a later stage of the healing process (Fig.

44.13).

The line of cutting describes a pattern of multiple waves, while the excision line is simply curved to end up with a congruence of the sutured edges (Fig. 44.14).

The prehairline incision is situated on a transition zone of skin pigmentation, comparable to the periareolar incision in breast surgery (Fig. 44.15a).

The healing process in that area is extremely good if a correct suture technique is applied. After 1 year the incision lines will be hardly visible (Fig. 44.15b).

Fig. 44.12. a Temporal traditional inci- sion inside the temporal hair always leads to posterosuperior displacement of the sideburn. b Hairline distortion and hairloss inside the temporal hair- bearing skin can be avoided with a prehairline incision

Fig. 44.13. Beveling the incision provides regrowth of hair through the prehairline scar in a later stage of healing

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44.4.2

Operative Technique

The periauricular incision is before the hairline in front of the ear; the postauricular incision is never before the hairline but extends into the hair-bearing zone dorsal to the mastoid.

After a soft-tissue undermining in the cheek and neck area and hemostases (the anesthetist raises the blood pressure to about 110 mmHg during that period) and application of the two-component fibrin seal (Tissucol), the key stapler clamps in front and behind the ear are positioned, followed by stepwise resection of the redundant skin. The hairline behind the ear is readapted through a third stapler clamp. A drain is applied over the mastoid. The prehairline requires meticulous suture technique. An intradermal run- ning suture with 5.0 Vicryl rapid is recommended.

The excised skin in the prehairline cervicofacial rhytidectomy is not hair-bearing except for a small triangle of the posterior hairline over the mastoid (Fig. 44.16).

With the mainly vertical orientation of vectors and the significant amounts of advanced skin to be resect- ed, especially from the cheek, a dramatic elevation and postero-superior displacement of temporal hair would occur with the traditional incision inside the hairline.

Short scar and minimal incision techniques [1, 15]

are without doubt highly appreciated but seen from another perspective – the necessity of skin reduction – it is the author’s experience that patient satisfaction depends more on the quality and position of the scars than only on their length. Especially for good access to the neck/platysma, a postauricular incision is un- avoidable. Good-quality prehairline and periauricu-

Fig. 44.14. The incision line is waved;

the skin excision line is simply curved

Fig. 44.15. a The prehairline incision is situated on a transition zone of skin pigmentation, comparable to the periareolar incision in breast surgery.

b Prehairline incision after 1 year

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lar scars can be obtained by avoiding traction of the skin edges.

The only moment when a tension is applied is the positioning of the pre- and postauricular key stapler clamps before skin excision. Choosing the right tension in that maneuver will determine the quality of the result. Every following redraping of the mobilized skin flap is done without tension. The sutures have to be applied with meticulous precision, respecting every single hair follicle!

44.4.3

The Terrace-Like Cranial Extension of the Temporal Prehairline Incision!

If there is a bunching up of skin in the temporal area, the prehairline technique can be extended cranially by a stepwise superposition of fusiform skin excisions in the temporal zone and the lateral forehead [13, 17].

These complementary incisions are done without any skin undermining just to flatten down the skin cranial to the point where the prehairline sideburn incision ends, to redrape bunching-up skin higher up.To strictly avoid visible scars, it is of special importance that these additional skin excisions are placed horizontally or slightly curved, never vertically (Figs.

44.17, 44.18), so that they are covered by the overlaying hair.

A combination of cervicofacial rhytidectomy with a browlift is the most complete facial rejuvenation!

In a high forehead, it is advisable to perform this as endoscopically controlled prehairline biplanar forehead advancement [14]. The incision lines are not co- herent, but the sideburn prehairline incision at the level of the upper pole of the helix and the forehead incision are performed as separate incisions horizontally. The prehairline incision at the frontal hairline

“feathers” into the lateral hair-bearing zone on each side.

Fig. 44.16. The excised skin in the prehairline cervicofacial rhytidectomy is not hair-bearing except for a small triangle of the posterior hairline over the mastoid

Fig. 44.17. The stepwise terrace-like cranial extension of prehairline incisions

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Fig. 44.18. Patient of 49 years of age, a before, b 1 week after and c 3 months after SACS rhytidectomy and terrace lifting. Note the inconspicuous scars positioned in the same “geometry” as the overlaying hair is directed

Fig. 44.19. a Preopertive and b postop- erative pictures: prehairline cervicofacial rythidectomy combined with endoscopically controlled biplanar prehairline forehead advancement and a perioral and lip microfatgrafting [4]

for complete facial rejuvenation

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44.5 Author’s Experience

In a period of 6.5 years between October 1998 and March 2005, the supra-SMAS plane of dissection according to the principles of SACS [12] and ESP [16]

lifting techniques combined with the prehairline incision were applied by the author in 389 cases of cervicofacial rhytidectomy.

The patients’ degree of satisfaction with the result was high. No complaints have been reported regard- ing prehairline scars except in six cases (scar revision).

The following complications occurred:

Hematomas (mastoid/cheek)

return to the operating room 7

Suture dehiscence prehairline on one side 2 Hypertrophic scars (scar revision) 4

Early recurrence of jowling fat 8

Skin slough 2

Seromas 4

In the author’s experience, it is a highly appreciated if hairloss or hairline distortion can be avoided. The criteria of a modern facial contouring are fulfilled by the SCAS or ESP techniques because they provide an even distribution of volumes in cervicofacial rhytid- ectomies, a fully restored regular jawline and cervicomental remodeling, and flattening of the nasolabial fold and the jowls, without ending up with a “pulled”

or tight “facelifted” aspect.

44.6 Summary

The SACS and ESP-liftings are truly volumetric techniques of cervicofacial rhytidectomy. The plane of undermining provides direct access to the subcutaneous fat, the fat pads to be contoured, repositioned and modified, and the plane of the fibromuscular tissue (SMAS/platysma) to be addressed separately as well as to osteocutaneous release. It is an anatomically correct plane of dissection without vascular damage to the skin. The prehairline incision with terracelike extension to the temporal zones and lateral forehead, and removal of excess skin, secures the maintenance of the temporo-frontal hairline without distortion or hairloss on the sideburns.

Restoring facial harmony and naturally looking long-lasting results of facial contouring achieved by replacing volumes of the perioral, nasolabial and infraorbital regions using fatgrafting will fulfill today’s patients’ requirements in facial rejuvenation surgery.

Acknowledgements. The author greatly appreciates the personal teaching of Daniel C. Baker (New York, N.Y., USA) Sydney B. Coleman (New York, N.Y., USA), Joel J. Feldman (Cambridge, MA, USA), Sam T. Hamra (Dallas, TX, USA), Steven M. Hoefflin (Santa Monica, CA, USA) and Frank Trepsat (Lyon, France) of their philosophy and techniques in facial rejuvenation surgery as a visiting surgeon.

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