Abstract facial nerve injury or sensory disturbance. None of



Background: We propose a technical variation of the
minimally invasive suture suspension facelift.

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Methods: A novel variation of the minimally invasive
facelift is proposed. The technique consists of two components. The anterior
component addresses aging of the midface by anchoring the SMAS on to the sturdy
retroauricular supra-helical deep
temporal fascia using approximately 6-8 passes of a 4/0 Mersilene
suture. The posterior component addresses cervical aging by securing the
posterior edge of the platysma onto the sturdy mastoid fascia, using multiple
loops of a 4/0 Mersilene suture. This technique was performed on 100
consecutive patients between 2005 and 2010. 


Results: The technique was found to be safe due to
the plane of dissection remaining superficial to the parotid gland in the
anterior component. There were no instances of facial nerve injury or sensory
disturbance. None of the patients required a secondary procedure within the
first 18 months following the procedure.


Conclusions: This technique offers a safe and effective
option for patients who seek a facelift, especially in combination with other
procedures. It is envisaged that the use of multiple loops of suture to anchor
mobile tissue onto fixed sturdy fascia will contribute to the longevity of the
results. The limited skin undermining also makes this procedure a better choice
for smokers.

Keywords: Face Lift; Suture suspension; SMAS

Level of
Evidence: Level IV




Since the initial descriptions of rhytidectomy
techniques over a century ago1, an increased understanding of the process of
aging and facial anatomy has led to the evolution of  procedures into a plethora of modern
techniques. However, while advances have been made, there is no consensus on the
best facelift approach.


In their landmark paper, Mitz and Peyronie
described the superficial musculoaponeurotic system (SMAS)2, a layer of fibromuscular and adipose tissue
beneath the dermis and above the parotidomasseteric fascia.  This structure invests the mimetic muscles of
the face and is generally believed to be continuous with the temporoparietal
fascia superiorly and the platysma inferiorly. The discovery of the SMAS marked
a major paradigm shift in modern rhytidectomy, since the manipulation of the
SMAS can have a dramatic effect on the skin, subcutaneous tissues and muscles.
Understandably, a multitude of SMAS manipulation techniques have evolved. Many
of the initial techniques still widely practiced, focus on SMAS
suspension.  However, currently, the most
common techniques consist of SMAS tightening by segmental excision followed by
direct closure (SMASectomy)3 or SMAS imbrication and plication4.

Although both techniques create
traction on the SMAS, complications often include postoperative loosening and
rupture of the SMAS perhaps from “cheese wiring,” or tearing of the sutures
through it. Mustoe and colleagues reported that an early secondary rhytidectomy
was required in 6.3% of their patients, citing factors such as: suture-tearing force, viscoelastic properties
of the SMAS (tissue creep and stress relaxation), blood supply, and an attempt
to avoid an overly pulled appearance5. Kamer and colleagues indirectly reviewed the
longevity of superficial SMAS rhytidectomy and found that 11.4% of patients
required a secondary tuck procedure within 18 months of the initial procedure6. These findings are supported by an animal
model which suggests that suspension sutures may
have limited long-term effectiveness and an early failure rate7.


To address the issue of
longevity, numerous suture techniques and materials have been proposed, from
barbed sutures8 to complex cable sutures9 with varying degrees of
success. The scope of this paper is not to evaluate the myriad of rhytidectomy
techniques, but to focus on a novel SMAS suture suspension method. We discuss
our experience of a novel variation of the minimally invasive suture suspension
facelift technique in the first 100 consecutive cases in the practice of the
senior author (PBF) between 2005 and 2010.



Patient Evaluation


This variation of the minimally invasive
suture suspension facelift can be thought of as consisting of an anterior and
posterior component. The anterior component primarily addresses aging on the
midface and along the mandible, whilst the posterior component primarily
addresses cervical aging. Both components may be used independently or
together, as well as combined with other rejuvenation techniques such as
suction assisted liposuction (SAL), platysmorraphy, skin resurfacing, facial
implants and / or injectibles. During the initial assessment, one can determine
which components would best suit the patient by applying traction to the
patient’s midface in a superio-oblique direction. If a large amount of excess
skin remains in the cervical region, the posterior component should also be
considered.  In patients presenting
primarily with cervical aging and / or lipodystrophy, the posterior component
alone is sufficient.




The Anterior


The surgical
procedure may be carried out under general anesthesia or monitored anesthesia
care (MAC). The skin is marked as shown in figure 1. A novel 2 cm
retroauricular incision is made to allow exposure of the supra auricular muscle
and access to the deep temporal fascia. Next, the pre tragal skin flap is
undermined and elevated using the pretragal and sideburn incisions, allowing
exposure of the pre tragal SMAS. The placement of this incision below the
sideburns allows preservation of the sideburn hair.  Skin undermining continues as depicted in
figure 2. For better mobilisation, the preauricular SMAS can be transected along
the medial border of the ear past the earlobe. Next,
the SMAS is secured to the sturdy
retroauricular supra-helical deep temporal fascia using approximately 6-8
passes (according to the surgical aims and patient anatomy) of a braided 4/0
Mersilene suture (figure 3).

Next a long 4-0 Mersilene suture is used to
create continuous loops by taking bites from the deep temporal fascia down to
approximately 3-4 cm below the earlobe into the platysma / SMAS.  Since 2012, inspired by the description of
the Platysma auricular ligament (PAL) and Lore’s fascia, the modification of
incorporating bites of this structure has been added10.


Successive loops would be placed progressively
in an anterior and superior direction. 
On an individual patient basis, if a midface augmentation is
aesthetically desirable, the loops are continued more anteriorly and
superiorly, creating a cheek auto augmention effect (figure 4 cheek
augmentation). When palpable bulges are created within the suture loops, these
can be flattened either with additional sutures, or with flat spatula
electrocautery.  The skin is re-draped
and the excess is trimmed.  Closure in
our practice, is carried out with 4-0 Vicryl interrupted sutures for the
subcutaneous layer and intradermal (subcuticular) 5/0 prolene sutures, for the


The Posterior Component


The skin is
marked as shown in figure 1. The pre tragal incision extends inferiorly to the
earlobe, a small island of skin is preserved around the earlobe to facilitate
closure and the incision is extended posteriorly, approximately 2-3 mm anterior
to the postauricular sulcus. The incision is further extended depending on the
anticipated amount of skin to be excised. If large amounts of neck skin must be
repositioned and resected, then this incision should be designed to run along
the occipital hairline, to prevent a step off deformity. For patients requiring
less skin removal, an incision that transects the occipital hairline is more
appropriate. In these patients, the hairline closure is adjusted to avoid a
step off. A skin flap is then created with undermining in the deep subcutaneous
plane. The extent of the undermining is individualised based on cervical skin
laxity and is joined to the skin undermining carried out for the anterior
component. Next, an identical braided 4/0 Mersilene suture is used to suspend
the posterior edge of the platysma onto the sturdy mastoid fascia.  On average, 6-8 loops are required (figure
5). The excess skin is trimmed and the incision is closed in layers in a
similar fashion to the anterior component. The authors prefer to use 4/0 vicryl
for 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 anterior
and / or posterior components.  


procedures performed in studies involving human participants were in accordance
with the ethical standards of the institutional and/or national research
committee and with the 1964 Helsinki declaration and its later amendments or
comparable ethical standards.



One of the authors (PBF) noted no
complications in the first 100 procedures between 2005, when the procedure was
first performed and 2010, except, a small haematoma was detected in the
recovery room and drained at the bedside. There were no instances of infection
or wound dehiscence. Furthermore, there were no cases of motor or sensory
deficiency. Although no formal assessments of the results were carried out, all
patients were satisfied with their results. During that time period (2005 to
2010), none of the patients required a revision or secondary procedure.




























following 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 refinement


Figure 6: Before the
procedure (left) and 3 years following the procedure (right).

Case 2


A 76 year old gentleman
presented with laxity in the midface region. Only the anterior component of the
technique was applied in this case and the pictures presented are pre operative
and 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 cervical

Case 3


A 45 years old female presented
with cervical ageing. She was treated with SAL, chin augmentation and the
posterior component.



Figure 8: Before the procedure (left) and 2 years
following the procedure (right)








At present,
there is no consensus on the best facelift technique and the adage, “there are
as many face lift techniques as there are face lift surgeons,” is probably
still appropriate. This is partly due to differences in surgical training,
patient preferences and the anatomy of the patient. Minimally invasive
procedures with a swift recovery are popular with patients and sought by


Chang and
colleagues sought to address this with a systematic review comparing different
facelift techniques. While some important information was gleaned from the
literature, they concluded that the available studies were lacking in quality
and highlighted the need for better designed studies11.


and longevity of facelift techniques are important concerns for patients. The
few studies that have addressed the issue of longevity, have shown that within
an 18 month period following the initial procedure, between 6.3%5 and 11.4%6 of patients require a
secondary 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 to
the ear, describes the anchoring of the SMAS with multiple loops of suture to
the sturdy deep temporal fascia and Lore’s fascia.  The posterior component addresses cervical
aging by anchoring the platysma to the sturdy mastoid fascia.  The increased number of loops compared to
other suture suspension facelifts12 allows an even spread of
force across the tissue, reducing the possibility of the sutures ‘cheese
wiring’ through the tissue.  It is
envisaged that the choice of the sturdy fascia will contribute to more enduring
results. If “tissue creep” at the anchoring site contributes to failure, then
this technique’s use of a sturdy fascial anchoring point may increase the
longevity of the procedure.


The first
100 consecutive patients who underwent surgery with this technique were
satisfied with the efficacy of the results after one year. The technique was
also found to be safe with regards to facial nerve injury, with no reported
complications. This was attributed to the relatively safe dissection in the
anterior component, superficial to the parotid gland for the most part and the
consequent avoidance of deeper structures.


negative 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 technique
requires only limited skin undermining, it is potentially a better option for
smokers. The senior author (PBF) initially
chose this technique for patients with comorbidities, smokers, and in
combination with skin resurfacing. The results were encouraging enough to offer
it more widely. 


In summary, we describe a minimally invasive facelift
technique that advances the SMAS beneath a limited skin flap, utilizing
starburst design multivector permanent sutures to the deep temporalis fascia
and Lore’s fascia, and additionally incorporating a posterior vector to the
mastoid fascia as required. Our anecdotal experience with this technique has
been rewarding, with respect to a quick recovery, low complication rates, and
high patient satisfaction. Our encouraging initial experience suggests that a
prospective study looking at results, including longevity, would be valuable.




Acknowledgement is given from the rest of the authors to co-author Dr
Nicanor Isse MD for his significant early input to the conceptualisation and
development of the technique.



1.         Hollander E (1912) Die Kosmetische
Chirurgie, Handbuch der Kosmetik. Leipzig, Germany

2.         Mitz V, Peyronie M (1976) The
superficial musculo-aponeurotic system (SMAS) in the parotid and cheek area.
Plast Reconstr Surg 58:80–8 . doi: 10.1097/00006534-197607000-00013

3.         Baker DC (1997) Lateral SMASectomy.
Plast Reconstr Surg 100:509–513 . doi: 10.1097/00006534-199708000-00039

4.         White JB, Barraja M, Mengesha T, et al
(2008) Avoiding Early Revision Rhytidectomy: A Biomechanical Comparison of
Tissue Plication Suture Techniques. Laryngoscope 118:2107–2110 . doi:

5.         Rawlani V, Mustoe TA (2012) The Staged
Face Lift: Addressing the Biomechanical Limitations of the Primary
Rhytidectomy. Reconstr Surg 130: . doi: 10.1097/PRS.0b013e31826d15e9

6.         Kamer FM, Frankel AS (1998) SMAS
rhytidectomy versus deep plane rhytidectomy: an objective comparison. Plast
Reconstr Surg 102:878–81

7.         Warren R, Wilson W, Hawtof D (1993)
Long-term ineffectiveness of suspension material and musculofascial
suspensions: a rabbit model. Plast Reconstr Surg 91:1316–21

8.         Sulamanidze MA, Fournier PF, Paikidze
TG, Sulamanidze GM (2002) Removal of Facial Soft Tissue Ptosis With Special
Threads. Dermatologic Surg 28:367–371 . doi: 10.1046/j.1524-4725.2002.01297.x

9.         Sasaki GH, Cohen AT (2002) Meloplication
of the malar fat pads by percutaneous cable-suture technique for midface
rejuvenation: outcome study (392 cases, 6 years’ experience). Plast Reconstr
Surg 110:635-54–7

10.       O’Brien JX, Rozen WM, Whitaker IS, Ashton
MW (2012) Lore’s fascia and the platysma-auricular ligament are distinct
structures. J Plast Reconstr Aesthetic Surg 65: . doi:

11.       Chang S, Pusic A, Rohrich RJ (2011) A
systematic review of comparison of efficacy and complication rates among
face-lift techniques. Plast Reconstr Surg 127:423–433 . doi:

12.       Tonnard P, Verpaele A, Monstrey S, et al
(2002) Minimal access cranial suspension lift: a modified S-lift. Plast
Reconstr Surg 109:2074–86

13.       Rees TD, Liverett DM, Guy CL (1984) The
effect of cigarette smoking on skin-flap survival in the face lift patient.
Plast Reconstr Surg 73:911–5 . doi: 10.1097/00006534-198406000-00009

14.       Manassa EH, Hertl CH, Olbrisch RR (2003)
Wound healing problems in smokers and nonsmokers after 132 abdominoplasties.
Plast Reconstr Surg 111:2082–2087 . doi: 10.1097/01.PRS.0000057144.62727.C8

15.       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 the
incision of the anterior component

Figure 2



1: 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 in


Figure 4


Malar elevation after completion of surgery on
the right side



Figure 5


Completed anterior and posterior (arrowed)