In the course of 30 years of aesthetic surgery practice, I have gradually evolved a facial rhytidectomy technique that in my hands produces consistent results while minimizing complications. During my training, wide skin undermining and preauricular skin incisions were routine. Little consideration was given to hairline disturbance, and in many patients the aesthetic improvement was unpredictable and inconsistent. In 1972, Bruce Connell visited the Manhattan Eye, Ear and Throat Hospital and, using one of my clinic face lift patients, demonstrated a submental approach to treating the medial platysma cords. The next year, Sam Hamra borrowed one of my clinic patients to demonstrate the SMAS technique he learned while in practice with Mark Lemmon. To the best of my knowledge, these demonstrations represented the first time either of those techniques was performed in New York City. From these early observations, I learned it is always necessary to be analytical and that aesthetic surgery technique is continually evolving.

In my practice, I continued to evolve a rhytidectomy technique based on my experiences and ongoing education. No single technique best suits all patients, and ancillary procedures are frequently needed to optimize results.

In the past 8 years I have performed hundreds of facial rhytidectomies using a particular technique, the “anterior vertical SMAS lift,” or variations of it, to provide patients with predictable and pleasing aesthetic results. My diagnostic process involves identifying the key facial elements that must be addressed and customizing the surgical plan to achieve maximal improvement. Although I incorporate elements from the work of Sam Hamra, and Dan Baker, I offer significant differences that provide excellent results while minimizing the possibility of complications. I do not recommend this technique for the novice surgeon; execution requires comfort with sub-SMAS dissection and an excellent knowledge of surgical facial anatomy.

Analysis of key facial elements

I begin analyzing key facial areas in each patient to determine how best to achieve aesthetically pleasing results (Figure 1). A preauricular incision is less troublesome and time consuming than a peritragal or retrotragal incision, and in about one-third of rhytidectomies, I am able to use this approach. A mature man or woman generally has a well-defined crease in which the incision can be discreetly placed. However, in younger patients, or if the patient frequently wears her hair back or in a short style that exposes the preauricular area, a peritragal approach is preferable, just as it is when no well defined preauricular crease exists.

To optimize the aesthetic outcome of a face lift, first consider key elements of the face and neck. Hairline height is marked against a fixed point (the ear) and should never be raised more than 1.5 cm above this point. If there is no preauricular crease, use a retrotragal incision. If the malar region is flat, and there is a triangular “hollow” just inferior and lateral, as well as a “bunching up” of subcutaneous tissue cephalad to the nasolabial crease, an anterior vertical SMAS lift is indicated. Consider fat injections or the use of alternate biologic fillers if the nasolabial crease is particularly deep. The jowls will substantially improve with the lift but may also benefit from lipoplasty for further contouring. Correction of microgenia dramatically improves the profile and improves definition of the submental area. I usually suction the submental region. If there is an arch-like appearance to the medial cords (ie, their vertical expanse is separated but the cords meet in the submental region), I will open this area and suture the medial cords. Posterior and superior rotation of the lower SMAS will change the jawline. Open suctioning along this plane may also be necessary. I do not resect a prominent submandibular gland; I personally believe that the possibility of nerve injury is too great. I point it out to the patient preoperatively and explain that it will be present after the procedure. The sternomandibular trough requires careful analysis. While a blunted trough is consistent with a round or heavy face, a deeper trough will enhance an angular or thin face.

The relationship of sideburn to ear position must also be considered. I draw a line from the lowest portion of the sideburn across the ear at this same level; with vertical repositioning of the facial skin, the hairline should not be elevated more than 1.5 cm above this line. To prevent too much elevation, I plan for an additional transverse incision at the lower sideburn and then excise the dog-ear at this level. I have never found it necessary to continue the pretrichial incision superiorly along the anterior hairline.

I frequently perform submental suction lipectomy but rarely use a submental incision to address the cords, preferring a posterior approach to the platysma muscle. However, if there is a visible “arch” when the patient is viewed frontally, I believe this requires a submental incision and suturing of the medial plastysmal cords. When considering the relationship between chin, nose, and jawline, I do not hesitate to recommend a chin implant if I feel it will enhance the aesthetic result.

The sternomandibular trough is an important aesthetic unit delineated by the anterior sternomastoid muscle, the jawline, and a horizontal line from the angle of the jaw intersecting the sternomastoid muscle. It is described as a trough rather than a triangle to emphasize its depth or dimensionality. A deep, well-defined trough enhances the appearance of a well-defined jawline, as long as it is consistent with other facial features.

I have found the anterior vertical SMAS lift to be most effective in dealing with nasolabial folds in patients undergoing facial rejuvenation surgery. I frequently perform fat injections along the nasolabial fold, at the time the rhytidectomy is performed, to further enhance results. However, I do not find biologic fillers effective for treating the nasolabial line without a simultaneous face lift. To analyze this area, I examine the region between the malar prominence and the mound of tissue just cephalad to the fold. I assess whether the intervening area is flat or hollow and digital elevation of the mound improves the malar region and minimizes the fold. The anterior vertical SMAS lift specifically addresses these problems. Additionally, improvement of the marionette lines, if present, and contouring of the jowls and jawline are achieved.

I recently conducted an informal survey regarding the submandibular gland. I sent a brief questionnaire to 11 plastic surgeons across the United States who I believe perform the largest volume of face lifts yearly. One of the questions I asked was how they treat the submandibular gland. Interestingly, not one of them resects the gland. This is consistent with my own experience; I personally believe that the possibility of nerve injury is too great. I make certain the patient understands that the fullness under the jawline may not be substantially improved.

The jawline between the chin and sternomandibular trough is usually improved with the technique described. Some suctioning with a flat blunt cannula under direct vision may also be helpful in defining this area.

Surgical technique

Mark the anatomic landmarks with the patient sitting; include the malar prominence, angle of the jaw, the jowls, the medial platysmal cords, and the extent of submental fat. Administer appropriate anesthesia, then mark preauricular or peritragal incisions. Mark the inferior transverse extent of the sideburn in red and carry this mark onto the ear so that a fixed reference point is visible.

Infiltrate the entire surgical site with epinephrine containing local anesthetic, and prepare and drape the patient. Begin with a punctate incision in the submental crease. Here, insert a blunt 3-mm Mercedes-type cannula and carefully contour this area using suction. If I am dissatified with the result, I extend the incision for further defatting under direct vision.

On the first (infiltrated) side of the face, use a #15 blade to incise along the marked areas. If you marked a retrotragal incision, carefully dissect the skin from the underlying cartilage with nasal tip scissors. Dissection anteriorly and inferiorly superficial to the SMAS is accomplished in a few minutes with Mayo scissors and finger dissection. In the face, the dissection is carried only just beyond the line drawn between the malar eminence and the angle of the jaw (Figure 2 and Figure 3).