Abstract facial nerve injury or sensory disturbance. None of

Abstract Background: We propose a technical variation of theminimally invasive suture suspension facelift.  Methods: A novel variation of the minimally invasivefacelift is proposed. The technique consists of two components. The anteriorcomponent addresses aging of the midface by anchoring the SMAS on to the sturdyretroauricular supra-helical deeptemporal fascia using approximately 6-8 passes of a 4/0 Mersilenesuture. The posterior component addresses cervical aging by securing theposterior edge of the platysma onto the sturdy mastoid fascia, using multipleloops of a 4/0 Mersilene suture. This technique was performed on 100consecutive patients between 2005 and 2010.

  Results: The technique was found to be safe due tothe plane of dissection remaining superficial to the parotid gland in theanterior component. There were no instances of facial nerve injury or sensorydisturbance. None of the patients required a secondary procedure within thefirst 18 months following the procedure.  Conclusions: This technique offers a safe and effectiveoption for patients who seek a facelift, especially in combination with otherprocedures. It is envisaged that the use of multiple loops of suture to anchormobile tissue onto fixed sturdy fascia will contribute to the longevity of theresults. The limited skin undermining also makes this procedure a better choicefor smokers.

Keywords: Face Lift; Suture suspension; SMASLevel ofEvidence: Level IV Introduction Since the initial descriptions of rhytidectomytechniques over a century ago1, an increased understanding of the process ofaging and facial anatomy has led to the evolution of  procedures into a plethora of moderntechniques. However, while advances have been made, there is no consensus on thebest facelift approach.  In their landmark paper, Mitz and Peyroniedescribed the superficial musculoaponeurotic system (SMAS)2, a layer of fibromuscular and adipose tissuebeneath the dermis and above the parotidomasseteric fascia.

  This structure invests the mimetic muscles ofthe face and is generally believed to be continuous with the temporoparietalfascia superiorly and the platysma inferiorly. The discovery of the SMAS markeda major paradigm shift in modern rhytidectomy, since the manipulation of theSMAS can have a dramatic effect on the skin, subcutaneous tissues and muscles.Understandably, a multitude of SMAS manipulation techniques have evolved. Manyof the initial techniques still widely practiced, focus on SMASsuspension.  However, currently, the mostcommon techniques consist of SMAS tightening by segmental excision followed bydirect closure (SMASectomy)3 or SMAS imbrication and plication4.

Although both techniques createtraction on the SMAS, complications often include postoperative loosening andrupture of the SMAS perhaps from “cheese wiring,” or tearing of the suturesthrough it. Mustoe and colleagues reported that an early secondary rhytidectomywas required in 6.3% of their patients, citing factors such as: suture-tearing force, viscoelastic propertiesof the SMAS (tissue creep and stress relaxation), blood supply, and an attemptto avoid an overly pulled appearance5. Kamer and colleagues indirectly reviewed thelongevity of superficial SMAS rhytidectomy and found that 11.4% of patientsrequired a secondary tuck procedure within 18 months of the initial procedure6. These findings are supported by an animalmodel which suggests that suspension sutures mayhave limited long-term effectiveness and an early failure rate7.  To address the issue oflongevity, numerous suture techniques and materials have been proposed, frombarbed sutures8 to complex cable sutures9 with varying degrees ofsuccess.

The scope of this paper is not to evaluate the myriad of rhytidectomytechniques, but to focus on a novel SMAS suture suspension method. We discussour experience of a novel variation of the minimally invasive suture suspensionfacelift technique in the first 100 consecutive cases in the practice of thesenior author (PBF) between 2005 and 2010. Methods Patient Evaluation This variation of the minimally invasivesuture suspension facelift can be thought of as consisting of an anterior andposterior component. The anterior component primarily addresses aging on themidface and along the mandible, whilst the posterior component primarilyaddresses cervical aging. Both components may be used independently ortogether, as well as combined with other rejuvenation techniques such assuction assisted liposuction (SAL), platysmorraphy, skin resurfacing, facialimplants and / or injectibles.

During the initial assessment, one can determinewhich components would best suit the patient by applying traction to thepatient’s midface in a superio-oblique direction. If a large amount of excessskin remains in the cervical region, the posterior component should also beconsidered.  In patients presentingprimarily with cervical aging and / or lipodystrophy, the posterior componentalone is sufficient.  Technique The AnteriorComponent The surgicalprocedure may be carried out under general anesthesia or monitored anesthesiacare (MAC). The skin is marked as shown in figure 1. A novel 2 cmretroauricular incision is made to allow exposure of the supra auricular muscleand access to the deep temporal fascia.

Next, the pre tragal skin flap isundermined and elevated using the pretragal and sideburn incisions, allowingexposure of the pre tragal SMAS. The placement of this incision below thesideburns allows preservation of the sideburn hair.  Skin undermining continues as depicted infigure 2. For better mobilisation, the preauricular SMAS can be transected alongthe medial border of the ear past the earlobe. Next,the SMAS is secured to the sturdyretroauricular supra-helical deep temporal fascia using approximately 6-8passes (according to the surgical aims and patient anatomy) of a braided 4/0Mersilene suture (figure 3). Next a long 4-0 Mersilene suture is used tocreate continuous loops by taking bites from the deep temporal fascia down toapproximately 3-4 cm below the earlobe into the platysma / SMAS.  Since 2012, inspired by the description ofthe Platysma auricular ligament (PAL) and Lore’s fascia, the modification ofincorporating bites of this structure has been added10.

 Successive loops would be placed progressivelyin an anterior and superior direction. On an individual patient basis, if a midface augmentation isaesthetically desirable, the loops are continued more anteriorly andsuperiorly, creating a cheek auto augmention effect (figure 4 cheekaugmentation). When palpable bulges are created within the suture loops, thesecan be flattened either with additional sutures, or with flat spatulaelectrocautery.  The skin is re-drapedand the excess is trimmed.

  Closure inour practice, is carried out with 4-0 Vicryl interrupted sutures for thesubcutaneous layer and intradermal (subcuticular) 5/0 prolene sutures, for theskin.    The Posterior Component The skin ismarked as shown in figure 1. The pre tragal incision extends inferiorly to theearlobe, a small island of skin is preserved around the earlobe to facilitateclosure and the incision is extended posteriorly, approximately 2-3 mm anteriorto the postauricular sulcus. The incision is further extended depending on theanticipated amount of skin to be excised. If large amounts of neck skin must berepositioned and resected, then this incision should be designed to run alongthe occipital hairline, to prevent a step off deformity.

For patients requiringless skin removal, an incision that transects the occipital hairline is moreappropriate. In these patients, the hairline closure is adjusted to avoid astep off. A skin flap is then created with undermining in the deep subcutaneousplane. The extent of the undermining is individualised based on cervical skinlaxity and is joined to the skin undermining carried out for the anteriorcomponent. Next, an identical braided 4/0 Mersilene suture is used to suspendthe posterior edge of the platysma onto the sturdy mastoid fascia.  On average, 6-8 loops are required (figure5). The excess skin is trimmed and the incision is closed in layers in asimilar fashion to the anterior component. The authors prefer to use 4/0 vicrylfor the deeper layers and 5-6/0 prolene or staples for the skin.

 Prior to closure,a vacutainer drain is inserted across the undermined pockets of the anteriorand / or posterior components.    Allprocedures performed in studies involving human participants were in accordancewith the ethical standards of the institutional and/or national researchcommittee and with the 1964 Helsinki declaration and its later amendments orcomparable ethical standards.Results One of the authors (PBF) noted nocomplications in the first 100 procedures between 2005, when the procedure wasfirst performed and 2010, except, a small haematoma was detected in therecovery room and drained at the bedside. There were no instances of infectionor wound dehiscence. Furthermore, there were no cases of motor or sensorydeficiency. Although no formal assessments of the results were carried out, allpatients were satisfied with their results. During that time period (2005 to2010), none of the patients required a revision or secondary procedure.                          RepresentativeCases Thefollowing cases were sourced from the practice of one of the authors (PBF).

 Case 1 A 67 year old patient pre operative and 3 years post;anterior and posterior components, cervical lipoplasty, and refinementrhinoplasty. Figure 6: Before theprocedure (left) and 3 years following the procedure (right). Case 2 A 76 year old gentlemanpresented with laxity in the midface region. Only the anterior component of thetechnique was applied in this case and the pictures presented are pre operativeand 10 days post procedure.  Figure 7: Before the procedure (left) and 1 week following the procedure(right). Note the rapid recovery and transmitted improvement in the cervicalregion.

Case 3 A 45 years old female presentedwith cervical ageing. She was treated with SAL, chin augmentation and theposterior component.                Figure 8: Before the procedure (left) and 2 yearsfollowing the procedure (right)     Discussion  At present,there is no consensus on the best facelift technique and the adage, “there areas many face lift techniques as there are face lift surgeons,” is probablystill appropriate. This is partly due to differences in surgical training,patient preferences and the anatomy of the patient. Minimally invasiveprocedures with a swift recovery are popular with patients and sought bysurgeons.  Chang andcolleagues sought to address this with a systematic review comparing differentfacelift techniques. While some important information was gleaned from theliterature, they concluded that the available studies were lacking in qualityand highlighted the need for better designed studies11.  Efficacyand longevity of facelift techniques are important concerns for patients.

Thefew studies that have addressed the issue of longevity, have shown that withinan 18 month period following the initial procedure, between 6.3%5 and 11.4%6 of patients require asecondary tuck procedure.

Various causes have been cited, these include:abnormal blood flow, the viscoelastic property of the SMAS and suture tearing /weakness5. Our technique anterior tothe ear, describes the anchoring of the SMAS with multiple loops of suture tothe sturdy deep temporal fascia and Lore’s fascia.  The posterior component addresses cervicalaging by anchoring the platysma to the sturdy mastoid fascia.  The increased number of loops compared toother suture suspension facelifts12 allows an even spread offorce across the tissue, reducing the possibility of the sutures ‘cheesewiring’ through the tissue.  It isenvisaged that the choice of the sturdy fascia will contribute to more enduringresults. If “tissue creep” at the anchoring site contributes to failure, thenthis technique’s use of a sturdy fascial anchoring point may increase thelongevity of the procedure. The first100 consecutive patients who underwent surgery with this technique weresatisfied with the efficacy of the results after one year.

The technique wasalso found to be safe with regards to facial nerve injury, with no reportedcomplications. This was attributed to the relatively safe dissection in theanterior component, superficial to the parotid gland for the most part and theconsequent avoidance of deeper structures.  Thenegative impact of smoking on surgical outcomes has been well documented.

Smoking is associated with increased skin slough rates13, decreased wound healing14 and skin necrosis15. Since the techniquerequires only limited skin undermining, it is potentially a better option forsmokers. The senior author (PBF) initiallychose this technique for patients with comorbidities, smokers, and incombination with skin resurfacing. The results were encouraging enough to offerit more widely.

   In summary, we describe a minimally invasive facelifttechnique that advances the SMAS beneath a limited skin flap, utilizingstarburst design multivector permanent sutures to the deep temporalis fasciaand Lore’s fascia, and additionally incorporating a posterior vector to themastoid fascia as required. Our anecdotal experience with this technique hasbeen rewarding, with respect to a quick recovery, low complication rates, andhigh patient satisfaction. Our encouraging initial experience suggests that aprospective study looking at results, including longevity, would be valuable. Acknowledgements Acknowledgement is given from the rest of the authors to co-author DrNicanor Isse MD for his significant early input to the conceptualisation anddevelopment of the technique.

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      Chang LD, Buncke G, Slezak S, Buncke HJ(1996) Cigarette smoking, plastic surgery, and microsurgery. J. Reconstr.Microsurg. 12:467–474 Figure 1 Markings for theincision of the anterior componentFigure 2  Figure1: Skin marking,showing: (A) Retro-auricular or Sub-Auricular incision; (B)sideburn or zygomatic incision; (C) pre-auricular incision; (D)retro-lobular incision Figure 2  Limited Skin Undermining Figure 3 Anterior suspension inplace  Figure 4 Malar elevation after completion of surgery onthe right side  Figure 5 Completed anterior and posterior (arrowed)fixation