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(Facial rejuvenation)

Face and Neck lifting
A technique to obtain facial and neck rejuvenation, with minimal scars, providing excellent aesthetic outcomes and sooner patient recovery.

Surgical description
First of all, a preauricular incision and posterior to the tragus is performed, continuing behind the ear and stopping before the hairline. Thus, the final scar is minimum and completely hidden within natural ear folds.

Skin dissection at cheek level is limited stopping before the cheekbone.
In the neck, we perform a dissection associated to liposuction with flat and 2 mm thin cannulas, and these areas are communicated with subcutaneous cheek dissection providing excellent jawline definition.

Afterwards, we focus on muscle plane. Our SMAS (Superficial Muscle Aponeurotic System) flap technique is presented. Differing from traditional facelift techniques, SMAS is not dissected completely although providing good results, because this tissue that is dissected from the skin and deeper plane is devascularized and thus, it atrophies. For that reason, after one or two years, patients who underwent one of this traditional facelift techniques with complete SMAS dissection, present a hollow looking face, skeletonized, due to subcutaneous atrophy. We perform SMAS pulling without dissecting it, raising a flap, which is transposed and sutured behind the ear, defining the angle of the mandible properly.

If platysmal bands are present in anterior neck, we perform an incision within a submental fold having access to platysma muscle and we suture it. In this way, a muscle “necklace” is formed working as a brassier that helps to keep the tissue in position along the midline providing a 90 degrees angle in the neck.

Afterwards, skin is pulled up and preserving the hairline, excess of skin is removed tailoring the skin flap and suturing it without any tension. SMAS bears all tension and avoiding its dissection, its atrophy is avoided as well. Skin overlying cheekbone is not undermined and pulling the skin flap, malar fat pad is elevated and repositioned.

Once the procedure is over and in an attempt to shape an oval face, we perform lipofilling with fat grafts enriched with platelet growth factors within the malar region. This fat graft takes very well herein, provided that skin is not undermined.

Combining all these procedures, minimal scar lifting, liposuction and dissection of anterior neck with flat minicannula, muscular “necklace” made from SMAS flap avoiding dissection to prevent atrophy, cheekbone lipofilling with fat graft enriched with platelet growth factors, we achieve very satisfactory facial rejuvenation along with very light surgical insult.

Type of patients
According to different parameters, we can distinguish:

Group 1
This group involves the majority of women between 35 and 50 years old. Facial changes due to aging are considered light to moderate.

Group 2
This other group involves women over 50 years old with facial aging changes considered to be advanced or severe.


Each group features and surgical procedures suitable for each case are:

Group 1
Involves women between 35 and 50 years old, with facial aging changes assessed as light to moderate, with facial and neck flaccidity but without broad and noticeable bands of the platysma muscle.

- Skin: in this group the incision is placed preauricularly from the rim of the sideburn, along the internal border of the tragus in the ear and continuing by the inferior and posterior border of the ear, stopping before the posterior hairline. With this type of incisions, scar is minimized and remains hidden within natural folds, preserving posterior hairline and sideburn. Subcutaneous dissection is performed to the mandibular rim and into the cheek, stopping before reaching the cheekbone, in order to properly expose and treat the SMAS.

- Fat: Liposuction is performed in anterior neck in these patients. We utilize a flat and 2 mm thin cannula providing precise control of areas to be treated. Performing superficial liposuction (over the muscular plane and under the skin) in a delicate way, an important reduction of double chin fat along with mandibular angle and neck definition is achieved. With this minimally invasive technique, very good aesthetic results in the neck are achieved.

- Muscular: Muscular plane of the face is traditionally treated by dissecting completely the SMAS and splitting it into different flaps used to pull up. These techniques produced hematoma and edema during postop. Furthermore, during the dissection, SMAS was dissected off the overlying and underlying tissues, being devascularized and finally atrophied. This fact results in an old looking and atrophied face within 1 or 2 years time. For that reason, more conservative ways of dealing with SMAS were developed like the Baker’s SMASectomy, performing removal of a strip of SMAS overlying parotid gland and avoiding facial nerve injury at the same time that SMAS is pulled up applying tension but without devascularizing the layer and thus, avoiding atrophy.

In our technique to treat the SMAS, after minimal skin incisions and SMAS exposure, a SMAS flap is raised overlying parotid gland similarly to Baker’s, parallel to nasolabial fold and 1 cm to anterior auricular border, as wide as necessary to erase the fold. The SMAS flap is not excised completely but pedicled inferiorly. The inferior limit of the flap reaches the platysma muscle, which is not sectioned nor included in the flap. Once the inferiorly based flap is raised, it is rotated 90 degrees backwards and anchored with stitches into the mastoid. The flap donor site is sutured and at the same time the muscular plane of the cheek is pulled and the mandibular line outlined. The SMAS flap sutured to the mastoid defines the cervical-mandibular angle without damaging or denerveting the platysma and the SMAS. With our technique, the characteristic atrophic faces following traditional facelifts are avoided because SMAS layer is not devascularized, and at the same time a precise definition of the angle of the neck is achieved with very satisfying aesthetic outcome.

Grupo 2
This group involves women over 50 years old, presenting major skin flaccidity in the whole face and especially in the neck with anterior platysmal bands and double chin. In these cases some variations to previously described techniques are introduced, but tailoring them to the needs of each case.

- Skin: Same incision as in group 1 is performed, but in some cases it has to be prolonged posteriorly.

- Fat: Cervical Liposuction is performed as well like in group 1.

- Muscular: SMAS is managed like in group 1, but the width of the flap varies according to the necessity of each case. In this group, anterior vertical bands in the neck are very common revealing platysma muscle waving. In these cases, small submental incision is performed and skin and subcutaneous tissue are dissected off the platysma. Once the muscle has been identified, both bands are dissected out and sutured in the midline of the neck correcting initial vertical bands. Furthermore, as tension is applied as well in the cheek and angle of the neck, a youthful neck with 90 degrees is the final postoperative result.

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