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InService Insights: Facelift anatomy, pre-op eval, techniques and complications


Nearly 124,000 facelifts were performed in 2019 by ASPS members, according to the Society's procedural statistics, which ranks it as the sixth most-performed aesthetic procedure. Its long duration in the Top 10 of the most-popular procedures mirrors its frequency in the In-Service/Self-Assessment Exam. As previous exam questions have focused on facial anatomy, preoperative evaluation, facelift techniques and management of common complications, this installment of InService Insights will revisit those areas in order to provide additional guidance.

Pertinent anatomy

The face and neck are composed of continuous soft-tissue layers through which the branches of the facial nerve reliably cross. Immediately deep to the subcutaneous plane, the superficial fascia is known as the galea aponeurotica (scalp); temporoparietal fascia (lateral upper face); superficial musculoaponeurotic system/SMAS (midface and lower face); and platysma (neck). The deep fascia is known as the periosteum (scalp); deep temporal fascia (lateral upper face); parotidmasseteric fascia (midface); and deep cervical fascia (neck).

All branches of the facial nerve run deep to the superficial fascia layer, making dissection in the subcutaneous plane safe. Outside of the parotid region, the branches of the nerve cross between the deep and superficial fascia, increasing the risk of injury. The frontal and marginal mandibular branches are the most feared during facelift surgery, due to their minimal cross-over with other branches. Injury to the buccal or zygmoatic branches is often clinically insignificant due to rich arborization.

The path of the frontal branch can be estimated by Pitanguy's line, which courses from a point 0.5-cm inferior to the tragus to a point 1.5-cm superior to the lateral eyebrow. After crossing the middle-third of the zygomatic arch just above the periosteum, the rami cross from deep to the deep temporal fascia to a level immediately deep to the temporoparietal fascia.

The marginal mandibular branch exits the caudal aspect of the parotid gland and travels anteriorly. In 20 percent of patients, it will initially travel below the mandible. After passing superficial to the facial vessels, it's always superior to the inferior mandibular border. It then continues anteriorly to innervate the depressor anguli oris (DAO) on its undersurface.

The cervical branch travels into the neck posterior to the gonial angle in a sub-platysmal plane. Cervical branch injuries can mimic marginal mandibular injuries, as both the platysma and the DAO depress the corner of the mouth. With cervical branch injury, however, lower-lip eversion will remain present through persistent mentalis muscle function.

The great auricular nerve (GAN) arises from the cervical plexus to provide sensory innervation to the earlobe. The GAN follows a parallel course posterior to the external jugular vein and crosses the mid-belly of the sternocleidomastoid muscle 6-7 cm below the external auditory canal (McKinney's point).

Preoperative evaluation

The typical signs of facial aging include rhytids, deepening of facial folds (nasojugal groove, nasolabial folds, marionette lines), soft-tissue ptosis, development of jowls, midface volume loss, obtuse cervicomental angle, excess neck skin, platysma laxity and platysma banding. Overall, the youthful face is considered to be an inverted triangle, whereas the aged face takes on a more square shape.

The most important preoperative risk factor to identify is a history of hypertension, particularly poorly controlled hypertension, as this is a risk factor for hematoma. Cigarette smoking should be stopped at least four weeks prior to facelift surgery, as active smokers have a 12-fold increased risk for wound-healing complications.

Genetic skin conditions such as cutis laxa, Ehlers-Danlos, progeria and elastoderma should be screened. While patients with cutis laxa can safely undergo facelift surgery, the other listed conditions increase the risk for wound-healing complications.

Surgical technique

Facelift surgery can be performed under general anesthesia or intravenous sedation. The use of intravenous sedation has been associated with a lower risk of deep venous thrombosis and pulmonary embolism.

Facelift techniques differ in how they treat the underlying SMAS and platysma. A subcutaneous facelift does not directly treat the underlying soft tissues. Rather, it removes excess skin and relies on skin tension to reposition the deep structures. Excessive tension on the skin increases the risk of wound-healing issues, abnormal scarring, abnormal flattening of the face and early recurrence of aging changes.

Various SMAS tightening techniques have been described to reshape the deeper structures and decrease tension on the skin closure. These techniques include SMAS plication, cranial suspension with looped sutures, SMAS excision (SMASectomy) and elevation of a SMAS flap. Large systematic reviews have not demonstrated the superiority of one technique over another.


The most common complication in facelift surgery is hematoma. Risk factors for hematoma formation include male gender, history of hypertension, NSAID use, elevated BMI and smoking. Strict perioperative blood-pressure control with clonidine has been shown to significantly decrease hematoma incidence, particularly in male patients. Hematomas should be treated with prompt return to the O.R. for evacuation. To minimize wound-healing issues, thick skin flaps should be raised and minimal tension should be placed on the skin closure. Excessive tension around the lobule will lead to a pixie ear deformity, which is defined as an anterior-tethered appearance of the healed lobule.

Facial nerve transection is rare. Transient nerve dysfunction immediately following a facelift is relatively common and likely due to the residual effects of the local anesthetic. Persistent dysfunction after the local anesthetic has worn off may be caused by suture placement, traction or thermal damage from the use of cautery. These issues should spontaneously resolve within days or weeks. Nerve dysfunction that persists beyond the initial postoperative period should resolve within three to four months. Chemodenervation of the contralateral muscle groups during this period can be performed with botulinum toxin to achieve better symmetry.

Similarly, GAN disturbances usually resolve spontaneously. Lower-ear numbness should initially be treated with observation. Persistent numbness and allodynia six to 12 months postoperatively can be treated with surgical exploration to release an entrapped nerve or excise a neuroma.

Parotid fistula and sialocele development following facelift surgery have been described. Initial treatment consists of serial aspiration, diet modification and scopolamine patches. Refractory cases are best treated with intra-gland injection of botulinum toxin.

Dr. Sinclair is PGY-5 in Integrated Plastic Surgery at Cleveland Clinic.