(Facial rejuvenation)

A technique to obtain facial and neck rejuvenation, with minimal scars, providing excellent aesthetic outcomes and rapid recovery without the side effects of aggressive facelift.

Volumetric versus gravitational facial rejuvenation

Classical facelift techniques apply the gravitational concept – that is they assume that skin tissue becomes loose due to gravity. Wide dissections are performed with large scars that distort the hairline and give a rigid, unnatural facial appearance. And if the facial tissues are already aging, excessive dissection and traction harms them even more.

We think that an aging tissue needs to be improved. To do so, we use stem cells from the fat tissue of the patient. We want to avoid large scars that disrupt the hairline and sideburns.

Facial aging causes sagging and atrophy of the tissues, with an increase in the height of the lower eyelids, dark circles, descent of the cheek fat pad, an increase in  the height of the upper lip, and marked nasolabial folds. All these features require volume replacement. This is what we term the volumetric concept.

Our facelift technique performs a very conservative detachment and avoids tissue atrophy. It allows fat grafting with cells from the patient's own fat tissue, which is rich in stem cells and undergoes different processing methods depending on the area to be injected: macrofat, microfat, SNIF, emulsion, and nanofat.

Comprehensive rejuvenation must solve the gravitational problem but must be conservative to avoid the signs associated with old facelift techniques. It must also be  volumetric in order to remodel and rejuvenate facial tissue.

Surgical description
First, we perform an incision behind the ear, stopping before the hairline. This means that the final scar is minimal and is completely hidden within natural ear folds.

Skin dissection in the cheek is also limited to the area above the parotid gland, stopping before the cheekbone.

In the neck, we perform moderate dissection and liposuction with thin, flat 2 mm cannulas, joining these areas to the subcutaneous dissection of the cheek and thus obtaining an excellent jawline definition.
Next, we focus on the muscle plane, using our SMAS (Superficial Muscle Aponeurotic System) flap technique. In contrast to traditional facelift techniques, the SMAS is not dissected completely; in spite of its good results, if this tissue is detached from the skin and the deeper tissues, it loses its blood supply and may atrophy. Within one or two years, patients who undergo traditional facelift with complete SMAS dissection often present a very hollow-looking face. We stretch the SMAS without dissecting it, creating a flap which is transposed and sutured behind the ear, thus obtaining an excellent definition of the angle of the mandible.

If platysmal bands are present in the neck, we perform an incision within a submental fold to gain access to the platysma muscle and then suture it. In this way, a muscle “necklace” is formed which helps to keep the tissue in position along the midline, creating a 90 degree angle in the neck.

Then, the skin is pulled up and, while preserving the hairline, the excess skin is removed and the remaining skin is sutured without any tension. The SMAS bears all the traction and, since it is not dissected, it does not atrophy. The skin overlying the cheekbone is not undermined and, with the traction of the skin flap, the malar fat pad is raised and positioned correctly

Combining all these procedures – minimal scar lifting, liposuction and dissection of the anterior neck with a flat minicannula, the creation of a muscle “necklace” made from the SMAS flap without detaching it so as to prevent atrophy, and cheek lipofilling with fat graft enriched with platelet growth factors – we achieve a highly satisfactory facial rejuvenation using a minimally-invasive approach.

Type of patients
Broadly speaking, our patients can be divided into two types:

Group 1
This group includes women between 35 and 50 years old. The changes due to aging are slight to moderate, with some flaccidity in the face and neck but without the broad, noticeable bands of the platysma muscle.

- Skin: In this group, a preauricular incision is made from the rim of the sideburn, along the internal border of the tragus and continuing along the inferior and posterior border of the ear, stopping before the posterior hairline. With this type of incision, the scar is minimized and remains hidden within natural folds, and the posterior hairline and sideburn are preserved. We perform subcutaneous dissection as far as the mandibular rim and the cheek, stopping before we reach the cheekbone, in order to expose and treat the SMAS.

- Fat: Moderate liposuction is performed in the neck with a flat, thin 2 mm cannula which achieves precise control of the areas to be treated. Performing gentle superficial liposuction (above the muscular plane and below the skin) achieves a significant reduction of the double chin fat and a good definition of the angle of the mandible and the neck. This minimally invasive technique obtains excellent aesthetic results.

- Muscle: Traditionally, the muscular plane of the face was treated by dissecting the SMAS and splitting it into several flaps which are used for traction. During the postoperative period, however, these techniques produced hematoma and edema. Furthermore, during dissection, the SMAS was detached from the overlying and underlying tissues, becoming devascularized and finally atrophied. The result is a haggard and tired look within one or two years. Furthermore, this technique requires a very large skin incision. If it is performed beyond the hairline it distorts the sideburn and neck; if it is done right on the hairline, in many cases it is visible and the result is both unsightly and permanent.

With a minimal skin incision along the lines of the insertion of ear and with only the portion of the SMAS covering the parotid gland exposed, we make an inverted U-shape flap parallel to the nasolabial fold and 2 cm from the anterior edge of the ear. The lower base of the flap reaches the platysma. Once this SMAS flap is lifted, it is rotated 90 degrees backwards, tractioned, and secured in the mastoid with stitches. 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 the platysma and the SMAS. Our technique avoids the characteristic atrophic faces following traditional facelifts because the SMAS layer is not devascularized, and at the same time a precise definition of the angle of the neck is achieved with a highly satisfactory aesthetic outcome. In addition, as we do not dissect the cheek, we can perform our fat grafting technique for integral facial rejuvenation.

Group 2
This group includes women aged over 50.

This group comprises women over 50 years old, with major skin flaccidity throughout face and especially in the neck, with anterior platysmal bands and double chin. In these cases some variations are introduced to the techniques described above, in order to respond to the needs of each case.

- Skin: The same incision is performed as in group 1

- Fat: Cervical liposuction is performed, as in group 1.

The SMAS is managed as in group 1, but the width of the flap varies depending on the case. In this group, anterior vertical bands in the neck are very common, revealing the folds of the platysma muscle. In these cases, via a small submental incision the skin and subcutaneous tissue are dissected from the platysma. Once the muscle has been identified, both bands are dissected and sutured in the midline of the neck, correcting the initial vertical bands. Furthermore, as tension is applied as well in the cheek and angle of the neck, a youthful neck with a 90º angle is obtained. We also apply our fat grafting technique in any areas of the face that require it.