The demand for facelifts is rapidly increasing in Asia because of economic development as well as the aging of the population. It is difficult to obtain satisfactory results, because of the facial characteristics of Asians. Various approaches, such as the extended superficial musculoaponeurotic system (SMAS) facelift, the finger-assisted malar fat elevation facelift, and the high SMAS facelift, were designed to improve facial sagging in the mid- and lower face with the development of advanced facial surgical procedures.
We reviewed facelift methods and surgical anatomy from the Asian viewpoint.
In Asians, skin is fibrous and richer in collagen, and retaining ligaments are tougher and more rigid. Facial features are flat and wide, so achieving satisfactory facelift results is a challenge. The release of retaining ligaments in the sub-SMAS plane is the most important procedure in Asian facelifts to achieve satisfactory results. Supplementing the SMAS dissection above the upper border of the zygomatic arch and elevating the malar fat pad through the prezygomatic space achieve better results in Asian facelifts.
The release of retaining ligaments in the sub-SMAS plane is the most important step during Asian facelifts for satisfactory results. The addition of SMAS dissection above the upper border of the zygomatic arch and malar fat pad elevation through the prezygomatic space help achieve better results for Asian facelifts.
The demand for facelifts is rapidly increasing in Asia because of economic development as well as the aging of the population. It is difficult to achieve satisfactory results, because of the facial characteristics of Asians. The goal of the facelift is to improve facial sagging. During initial stages, facelifts focused on the lower face. Various approaches, such as the extended superficial musculoaponeurotic system (SMAS) facelift, the finger-assisted malar fat elevation (FAME) facelift, and the high SMAS facelift, were designed to improve facial sagging in the mid- and lower face with the development of advanced facial surgical procedures [
Previously, facelift procedures were limited to skin excision. After methods of continuous incision, subcutaneous face and neck undermining, redraping, and excision of excess skin were recommended, establishing the principles of the facelift [
Basic techniques for the extended SMAS facelift are similar to traditional SMAS facelift techniques. With aging, dermal elastosis and skin laxity in the face do not occur in the same direction as the descending fat. These techniques then allow the raising of the dissected subcutaneous flap separate from the dissected SMAS flap, and these two layers can then be repositioned along two different vectors, [
Facelifts using the FAME technique first involved the lifting of the malar fat pad, as its elevation improves the appearance of the midface [
A traditional SMAS elevation done about 1 cm below the zygomatic arch cannot correct the midface effectively, because the effect of pulling the flap is limited to the lower cheek regions [
There are various retaining ligaments in the face [
SMAS flaps with release of retaining ligaments in the sub-SMAS plane greatly improve facial sagging. If the retinacular cutis, which is a retaining ligament in the subcutaneous plane, were released in this plane, the skin flap would play an important role in the facelift. In addition, postoperative morbidity, such as scars, ear deformities, and relapse, would be higher, because the skin is not sufficiently tough and rigid to endure a lifting force. Thus, the SMAS flap, which is a tough and rigid tissue, has a main role in facelifts with the proper release of retaining ligaments in the sub-SMAS plane.
Care must be taken when dissection occurs near major structures, such as facial nerves, muscles, and the parotid duct, adjacent to the zygomatic and masseteric ligaments. We use a tumescent solution for hydrodissection to provide a bloodless visual field. In addition, blunt Metzembaum scissors are commonly used for the release of these ligaments without the need for sharp dissection. Since the nerve runs obliquely and the ligaments are oriented vertically, the release should be performed in the upper portion. In this manner, ligaments can be reliably released and injury to the nerve can be avoided. In cases where the ligament and facial nerve branches are difficult to differentiate, then a nerve stimulator may be used to distinguish them.
We believe that the release of retaining ligaments is more important than malar fat pad elevation through the prezygomatic space and SMAS dissection above the upper border of the zygomatic arch for optimal facelift results. If the zygomatic and upper masseteric retaining ligaments are not released in the sub-SMAS plane, other procedures would only secondarily achieve good facelift results, because these ligaments act as barriers in the superoposterior direction.
In most Asian patients, the skin is thicker and more fibrous than that of a typical Caucasian. Asians also tend to have tougher and more rigid retaining ligaments. Facial features are flatter and wider due to prominent zygomas, zygomatic arches, and mandibular angles. Thus, achieving satisfactory results is a challenge [
Achieving satisfactory facelift results is relatively difficult in Asians. The release of retaining ligaments in the sub-SMAS plane is the most important step during Asian facelifts for satisfactory results. The addition of SMAS dissection above the upper border of the zygomatic arch and malar fat pad elevation through the prezygomatic space help achieve better results for Asian facelifts. More studies are necessary to redefine suitable facelift methods for Asians.
The author deeply appreciate Prof. Song, Seung Yong for invaluable advice and encouragement and is grateful to Ms. Hong, Bichira for thoughtful consideration and exquisite illustrations.
No potential conflict of interest relevant to this article was reported.
The design for SMAS flap elevation is made on the SMAS in Extended SMAS facelift. Note SMAS design below lower border of zygomatic arch. There are zygomatic (black arrow) and upper masseteric retaining ligaments (red arrows) in sub-SMAS plane.
SMAS fixation above the upper border of the zygomatic arch (B) is more effective in correcting facial sagging in the midface than is SMAS fixation below the lower border of the zygomatic arch (A). Length of the arrows mean the tension of SMAS fixation. Long arrow has more tension than short arrow.
Malar fat pad is elevated through prezygomatic space under the orbicularis oculi muscle by finger.
The design for SMAS flap elevation is made on the SMAS above upper border of zygomatic arch in High SMAS facelift. There are zygomatic (black arrow) and upper masseteric retaining ligaments (red arrows) in sub-SMAS plane.