Evaluating the Effectiveness of the High-SMAS Facelift Technique: Objective Clinical Outcomes at 1-year.

BACKGROUND: The primary goal of the facelift is to rejuvenate the face without changing its natural features. This involves working on the deeper layers to preserve the surface look while adjusting the fat pads beneath. Thus, we often use a modified High-SMAS facelift method, following this deep-layer approach. The study evaluates whether the high-SMAS facelift, focusing on optimal repositioning, can effectively reduce aging signs in the mid to lower face and neck. METHODS: Conducted from 2018 to 2022, this retrospective cohort study included demographic data, relevant comorbidities, and operative details of patients undergoing lateral extended high-SMAS facial lifting, excluding revision cases. Complications were recorded, and a minimum one-year follow-up was ensured. The technique's effectiveness was assessed using pre- and one-year post-surgery images analyzed by three masked examiners with a validated scoring method by La Padula et al. RESULTS: The study included 325 patients, with no major complications reported. Significant improvements were noted in post-operative High-SMAS visual scores compared to pre-operative scores (p < 0.0001), particularly in cheek fullness, jawline, and cervical angle definition. CONCLUSIONS: The High-SMAS facelift technique, evaluated using the Face- and Neck-Lift Objective Photo-Numerical Assessment Scale, demonstrated significant cosmetic enhancements. This technique, focusing on optimal flap draping vectors, effectively restores a youthful appearance by improving facial contours. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors   www.springer.com/00266 .

The Surgical Anatomy of the Jowl and the Mandibular Ligament Reassessed.

INTRODUCTION: A visible jowl is a reason patients consider lower facial rejuvenation surgery. The anatomical changes that lead to formation of the jowl remain unclear. The aim of this study was to elucidate the anatomy of the jowl, the mandibular ligament and the labiomandibular crease, and their relationship with the marginal mandibular branch of the facial nerve. MATERIALS AND METHODS: Forty-nine cadaver heads were studied (16 embalmed, 33 fresh, mean age 75 years). Following preliminary dissections and macro-sectioning, a series of standardized layered dissections were performed, complemented by histology, sheet plastination and micro-CT. RESULTS: The jowl forms in the subcutaneous layer where it overlies the posterior part of the mandibular ligament. The mandibular ligament proper exists only in the deep, sub-platysma plane, formed by the combined muscular attachment to the mandible of the specific lower lip depressor muscles and the platysma. The mandibular ligament does not have a definitive subcutaneous component. The labiomandibular crease inferior to the oral commissure marks the posterior extent of the fixed dermal attachment of depressor anguli oris. CONCLUSION: Jowls develop as a consequence of aging changes on the functional adaptions of the mouth in humans. To accommodate wide jaw opening with a narrowed commissure requires hypermobility of the tissues overlying the mandible immediately lateral to the level of the oral commissure. This hypermobility over the mandibular attachment of the lower lip depressor muscles occurs entirely in the subcutaneous layer to allow the mandible to move largely independent from the skin. The short, elastic subcutaneous connective tissue, which allows this exceptional mobility without laxity in youth, lengthens with aging, resulting in laxity. The development of subcutaneous and dermal redundancy constitutes the jowl in this location. LEVEL OF EVIDENCE IV: "This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 ."

Cephalometric analysis following combined Sub-SMAS hyaluronic acid injection and subdermal and supraperiosteal poly-L-lactic acid injections in Asian women.

BACKGROUND: The aging face is characterized by skin laxity and volume loss. Attenuation of facial retaining ligaments significantly contributes to skin sagginess and soft tissue volume loss. AIMS: We designed a prospective cohort study to quantitatively assess the efficacy of hyaluronic acid (HA) with adjunct poly-L-lactic acid (PLLA) injections in strengthening the retaining ligaments. PATIENTS/METHODS: A total of 12 Asian women were treated with HA injections to the orbital, zygomatic, buccal-maxillary, and mandibular retaining ligaments with adjunct supraperiosteal and subdermal PLLA injections to the temporal region, midface, and lower face. Cephalometric measurements were done before treatment and 2, 4, 12, and 24 weeks post-procedurally. RESULTS: Eyebrow peak and tail angles increased 20.0° ± 3.8° to 21.0° ± 3.8° (p < 0.05) and -2.9° ± 4.2° to -1.3° ± 3.3° (p < 0.001) at week 12. Eyebrow-to-orbital-rim distance increased 1.9 ± 2.0 mm to 3.9 ± 1.5 mm (p < 0.001) at week 12. Eyebrow-to-upper-eyelid distance increased 11.6 ± 3.0 mm to 12.7 ± 3.2 mm (p < 0.001) at week 24. Eyebrow-peak-to-lateral-limbus distance decreased 6.1 ± 3.1 mm to 5.3 ± 2.4 mm (p < 0.05) at week 4. Tragus-oral-commissure length and lower-facial-contouring length decreased 281 ± 11 mm to 275 ± 10 mm (p < 0.01) and 297 ± 14 to 292 ± 11 mm (p < 0.05) at week 12, respectively. CONCLUSION: Hyaluronic acid injection for strengthening of facial retaining ligaments with adjunct PLLA is viable, safe, and effective in facial rejuvenation as supported by quantitative data.

Asian Facelift.

The Asian facelift requires an adaptation of current techniques to achieve a desired aesthetic outcome. Cultural differences and differences in anthropomorphologic features alter a patient's vision of beauty and youthfulness. Rejuvenation of the aging Asian face mandates a set of strategies, including understanding cultural aspects of Asian patients, anatomy of Asian patients, and appropriate techniques based on these cultural and anatomic considerations. For stable application and results, the surgeon must understand surgical facial anatomy. If performed properly, facelifts can improve facial balance and can yield aesthetically more appealing results. The deep plane facelift technique presented is well suited for Asian patients.

Cervicomental angle definition in the youthful patient (less than 40 years).

In clinical practice nowadays, one is faced with a group of patients still in their youth, demanding a more defined cervicomental angle. This specific group, aging less than 40 years of age, while the classical approach in this population addresses the osseous structures as per genioplasty or mental prosthesis, and for soft tissue definition, they frequently undergo submental liposuction. We noticed that in certain cases this is not enough and the patients can be still dissatisfied, these patients can highly benefit from our technique using the digastric corset in order to restore this congenital absence of cervicomental angle definition. This technique addresses and treats the anatomical malposition of the floor of the mouth, resulting in cervicomental angle widening in the youthful individual. In this technical note we will state the anatomical detail explaining its specific indication and benefit, specifically in this age group.

Vectorial facial sculpting: A novel sub-SMAS filler injection technique to reverse the impact of the attenuated retaining ligaments.

BACKGROUND: Age-related attenuation of the orbital, zygomatic, and masseteric ligaments contribute to temporal brow ptosis, deepening nasolabial fold, and jowl, respectively. AIMS: To present and assess the vectorial facial sculpting (VFS) technique, a novel nonsurgical panfacial rejuvenation method which focuses on reversal of the impact of attenuated ligaments on the aging face. METHODS: This case series included women who underwent vectorial facial sculpting at a private clinic from June 2018 to January 2019. Sagging tissues in the lateral brow, nasolabial fold, and jowl were repositioned in a directed manner with vectors whose cross-product counteracted the vector of the respective causative attenuated ligament. Filler material was deposited into the supraperiosteal/sub-SMAS plane in right angle vectors at the lateral supra-orbital rim for brow ptosis, pre-auricular and malar region for nasolabial fold and across the jawline region for jowl. Standardized photographs were taken before and at 3 months following treatment. Outcome was assessed by both the patients and an independent investigator using a validated Global Aesthetic Improvement Scale. Adverse outcomes were documented. RESULTS: Forty-five patients of mean age 59.8 ± 3.9 years were included. Mean Global Aesthetic Improvement Scale scores for patients and an independent investigator alike at 3 months following treatment indicated "very much improved" (1.44 ± 0.66 and 1.56 ± 0.78, respectively). The procedure was well tolerated with no adverse events. CONCLUSION: Vectorial facial sculpting is a comprehensive anatomical approach for nonsurgical directional tissue mobilization. Based on physical and mathematical rules to reverse the respective causative attenuated ligament, the technique effectively and safely restores youthful facial contours.

Facelift: History and Anatomy.

In this article, we review the history of the facelift operation and how it evolved from skin excision only to the modern superficial musculoaponeurotic system operation. We describe the critical surgical anatomy of the facial layers, retaining ligaments of the face, facial spaces, the 3-dimensional complex course of the facial nerve branches, and the pertinent anatomy of the neck. This article is supplemented by fresh cadaver anatomic dissections.

Extended Deep Plane Facelift: Incorporating Facial Retaining Ligament Release and Composite Flap Shifts to Maximize Midface, Jawline and Neck Rejuvenation.

This article describes our extended, deep plane facelift technique. This procedure releases 4 key retaining ligaments in the face and neck, the zygomatic cutaneous, masseteric cutaneous, mandibular cutaneous, and cervical retaining ligaments. Once released, the composite deep plane flap is repositioned to volumize the midface and gonial angle. Important anatomic considerations during deep plane dissection are discussed. In the neck, focus is on extending the deep plane dissection of the platysma, releasing the cervical retaining ligaments, creating a platysmal hammock to support the submandibular gland, defining the inferior mandibular contour, and minimizing the need to open the neck.

[The biplane microlift. Principles, technic, results]. / Le microlift biplan. Principes, technique, résultats.

There has been a growing number of patients asking for a lighter face lift than the classical biplane procedure with wide undermining; This explains the popularity of medical threads lifts. A surgical approach is nevertheless possible by performing a new technique, derived from minilfts, but with a dissection elevating skin and SMAS layers together, preserving as much retaining ligaments as possible, and allowing a predesigned skin excision. Thirty-two patients have been operated this way since 2014; 3 asked and sustained for a redo because of skin relapse at one year postoperatively. Few complications have occurred, mostly limited hematomas, or skin problems because of suture threads rejection. The best indications seemed to be young patients presenting a jowl ptosis or cervical skin laxity, and patients who require a secondary facelift as a lighter procedure.

[Anatomical basis for rejuvenation surgery]. / Bases anatomiques du tégument facial appliquées à la chirurgie du rajeunissement facial.

The understanding of the face anatomy is mandatory before to be able to appreciate the different surgical techniques of face lifting. Despite numerous controversies and anatomical variations, we can find in the literature several keystone works that allows us to understand that the soft tissues of the face are not only a superposition of layers but also a tridimensionnal structure with a fibrous system that links the different layers. This structures creates a mix loose spaces, fat and retaining ligament that can be describe in a quite systematic manner. This systematisation can help the surgeon during the surgical procedure to search and find the area where there is no danger and alert him around the retaining for example, which is where we can often find a vessel or a branch of the facial nerve that we want to avoid. This article summarizes these anatomical knowledge.

Presto lift-a facelift that preserves the retaining ligaments and SMAS tethering.

BACKGROUND: Producing youthful facial appearance by face-lifting often comes along with an undesired loss of patient's individual phenotype. This may result from insufficient preservation of retaining ligaments, the "guardians of facial identify," and from severance of the intersegmental connections of the superficial musculo-aponeurotic system (SMAS), which tether, structure, and compartmentalize facial soft tissue into defined, relevant anatomical zones. METHODS: The technique reported here preserves most retaining ligaments. They serve to fix the facial soft tissue mass in loco. With the possible exception of the zygomatic-cutaneous ligament, they are only carefully distended. The SMAS intersegmental connections and the zygomatic SMAS border are preserved to retain effective points of facial tissue fixture. Aging-associated thinning and lengthening of the lower eyelid are reduced by midfacial-submalar preparation (Aston 1996). Subplatysmal preparation and disconnection of the cranial-platysmal border permits optimal modeling of neck structure. RESULTS: The combination of preservation of retaining ligaments and SMAS tethering ("PRESTO facelift") introduced here as a novel face-lifting technique conserves the individual esthetics of the patient by approaching her/his individual phenotype from decades ago. In addition, undesired outcomes of facelift surgery and common risks of facelift surgery are circumvented. CONCLUSIONS: The PRESTO facelift technique generates optimal esthetic results that conserve a patient's personal facial identity, besides restoring a more youthful appearance and being rapid and safe.

Anatomical study and aging analysis of the labiomandibular fold / 中华整形外科杂志

Objective@#To discuss the formation mechanism of the aging characteristics of the labiomandibular fold in the lower face, through anatomical and histological study of the labiomandibular fold area.@*Methods@#①The methylene blue dye was injected into the jowl fat compartment and the labiomandibular fat compartment which were located in one side of the face of adult fresh cadaveric heads(5 male, 3 female), the labiomandibular fold area was the uncolored region which between the two colored fat compartments. ②Combining with the observation by eyes, symmetrical region of theobjective ly marked labiomandibular fold on the other side of the face in the same head was selected to dissect with microsurgery technique under microscope. The locations, characteristics and adjacent relationships of the anatomical structures of the labiomandibular fold were observed carefully. During the experiment, some related tissues were measured by vernier caliper and recorded by the text and image. ③The symmetrical region of the marked labiomandibular fold with the methylene blue dye (step①) was cut, dehydrated, imbedded in paraffin and serially sliced in cross-section with the thickness of 10 μm. After that, the sections were used to perform HE stain and Masson stain.@*Results@#The labiomandibular fold is the area of the face which located in the surface of the depressor anguli oris muscle and extends from the mouth corner to the mandibular border. The superior boundary of the labiomandibular fold is formed by the cutaneous insertion of the depressor anguli oris muscle around the mouth corner. The inferior boundary is the mandibular ligament. The lateral and medial area of the labiomandibular fold are the jowl fat compartment and the labiomandibular fat compartment respectively. However, the adipose tissue of the jowl fat compartment is bigger, thicker, looser and lighter in color. Theresult of the histologic evaluation are consistent with the findings of the gross anatomy.@*Conclusions@#According to the characteristics of the labiomandibular fold, there are many aspects of reasons for the emergence of the labiomandibular fold, such as the relaxation of the facial retaining ligaments associated with the labiomandibular fold and the descensus of the lateral soft tissue of the labiomandibular fold with age. In addition, the differences in structure and morphology between the medial and lateral fat compartments of the labiomandibular fold also play a vital role.

True retaining ligaments of face as surgical landmarks / Los verdaderos ligamentos de retención de la cara como marcadores quirúrgicos

The adherence of the overlying tissues to the underlying structures in the face is maintained by the retaining ligaments. True retaining ligaments named orbital, zygomatic and mandibular ligaments are a series of fibrous bands that run from periosteum to the dermis. The tethering effect of true retaining ligaments must be released for achieving a satisfactory movement of facial skin and Superficial Muscular Aponeurotic System (SMAS) during facial rejuvenation procedures. The aim of this study was to define the location of the true retaining ligaments of the face and to discuss their usability as surgical landmarks. The study was made on ten hemi-faces of formaline-fixed cadavers. Dissections resembling face-lift procedures were applied and ligaments were determined. The distances of the ligaments to lateral canthus, tragus and commissure and to the lines from tragus to lateral canthus and commissure were measured. Correlations were investigated statistically. The distances of the zygomatic and mandibular ligaments from the tragus were 66.50±10.78 mm and 114.80±9.76 mm respectively. The distances of the zygomatic ligament from the commissure and the commissure tragus line were 56.30±8.94 mm and 28.40±5.19 mm respectively. The distances of zygomatic and mandibular ligaments from the tragus were strongly correlated with a ratio of 3/5 and there was a strong correlation between the distances of the zygomatic ligament from the commissure and commissure- tragus line with a ratio of 2. The results of this study elucidated the possibility of the use of the true retaining ligaments as surgical landmarks for facial surgery.

La adherencia de los tejidos que recubren a las estructuras subyacentes en la cara se mantiene por los ligamentos de retención. Los ligamentos de retención verdaderos llamados ligamentos orbitales, cigomático y mandibular son una serie de bandas fibrosas que se extienden desde el periostio a la dermis. El efecto de la inmovilización de los verdaderos ligamentos de retención debe ser liberado para lograr un movimiento satisfactorio de la piel del rostro y del SMAS durante los procedimientos de estiramiento facial. El objetivo fue definir la ubicación de los verdaderos ligamentos de retención de la cara para discutir su utilidad como puntos de referencia quirúrgicos. El estudio se realizó sobre diez hemi-caras de cadáveres, fijadas con formalina. Las disecciones se asemejaron a los procedimientos de estiramiento facial, se aplicaron y determinaron los ligamentos. Se midieron las distancias de los ligamentos al canto lateral, trago, comisura y a las líneas de trago a canto lateral y comisura. Las correlaciones fueron analizadas estadísticamente. Las distancias de los ligamentos cigomático y mandibular desde el trago fueron 66,50±10,78 mm y 114,80±9,76 mm, respectivamente. Las distancias del ligamento cigomático a la comisura y la línea de comisura al trago fueron 56,30±8,94 mm y 28,40±5,19 mm, respectivamente. Las distancias de los ligamentos cigomático y mandibular desde el trago estaban correlacionadas de forma importante con una relación de 3/5 y había una fuerte correlación entre las distancias del ligamento cigomático desde la línea de comisura y el trago - con una relación de 2. Los resultados de este estudio han dilucidado la posibilidad de la utilización de los verdaderos ligamentos de retención como puntos de referencia quirúrgicos para la cirugía facial.

Detailed anatomy of the retaining ligaments of the mandible for facial rejuvenation.

PURPOSE: To present anatomical characteristics of three true ligaments of the mandible and better understanding of jowl formation. MATERIALS AND METHODS: Facial dissections were performed in 10 fresh cadavers (20 hemifaces) using 2.5 magnifying surgical loupes. Mental ligament, medial mandibular ligament, and mandibular osteocutaneous ligament were identified as thick fibrous tissue originating from the mandible. RESULTS: The location of the mental ligament was 9.1 ± 2.8 mm lateral to the midline and 8.4 ± 3.8 mm superior to the inferior border of the mandible. The medial mandibular ligament was located 28.5 ± 4.9 mm lateral to the midline and 8.4 ± 2.7 mm superior to the inferior border of the mandible. The mandibular osteocutaneous ligament was located 51.1 ± 4.5 mm lateral to the midline and 9.1 ± 3.1 mm superior to the inferior border of the mandible. CONCLUSIONS: We investigated location and tension of two unfamiliar ligaments in the mandible, the mental and medial mandibular ligaments medial to the mandibular osteocutaneous ligament, and confirmed them as true ligaments by histology. Our findings suggest that the cause of the jowl formation is mainly descent of the cheek fat compartments, but not laxity of mandibular osteocutaneous ligament.

Midcheek endoscopic anatomy.

BACKGROUND: Surgical approaches to the midcheek area are challenging. Recent clinical reports have proposed minimally endoscopic approach again, in order to obtain to obtain a correct balance between the operation's safety and the cosmetic and minimally invasive outcome, but none of them provides a careful anatomic description of the midcheek area. The purpose of this study was to provide a new anatomic perception of the midcheek area through a detailed anatomic endoscopic-assisted dissection. METHODS: Four freshly injected cadaver heads were dissected to illustrate the endoscopic anatomy of the midcheek region. RESULTS: An endoscope provided an excellent surgical window that achieved greater exposure for dissection and at the same time improved magnification of the noble key anatomic elements. CONCLUSION: This study emphasizes the critical role of the transverse facial artery and the facial retaining ligaments as a fundamental endoscopic landmark that allows the identification of key anatomic structures and the creation of safe surgical corridors. © 2015 Wiley Periodicals, Inc. Head Neck 38: E268-E273, 2016.

Retaining ligaments of the face: review of anatomy and clinical applications.

The retaining ligaments of the face are important in understanding concepts of facial aging and rejuvenation. They are located in constant anatomic locations where they separate facial spaces and compartments. Their superficial extensions form subcutaneous septa that separate facial fat compartments. Their main significance relates to their surgical release in order to achieve the desired aesthetic outcome. Furthermore, they have a sentinel role in their anatomic relationship to facial nerve branches. When performing facial aesthetic surgery, plastic surgeons should select a plane of dissection, release the appropriate ligaments depending on the desired aesthetic goals, and avoid nerve injury by using the ligaments as anatomic landmarks. Descriptions of the retaining ligaments are variable in the literature; due to different interpretations of anatomy, several classifications, locations, and nomenclature systems have been proposed. This article will review and clarify the anatomy of the retaining ligaments of the face, including the cheek, mandible, temporal, and periorbital areas.

Extended SMAS Facelift

In order to solve the problems related to aging faces, new techniques, including various kinds of barbed suture technique, are developing in present time. Although these several kinds of noninvasive or minimal invasive method for aging face have their own indication and barely complications, these procedures would be less effective than the extended SMAS technique used on those of Oriental person. In the face, there are some retaining ligaments, which support facial soft tissue against gravitational change. With aging, the cheek soft tissue anterior to the zygomatic ligament and posterior to the mandibular ligament descends into the plane between the superficial and deep fascia. However, the attached area by the zygomatic and mandibular retaining ligaments are almost unchanged because the ligaments that support facial soft tissue in normal anatomic position i.e, ligaments retain their integrity while the soft tissue around it relaxes. These changes lead to the formation of a nasolabial fold and jowl. I think the most important consideration factor before choosing a certain procedure is to decide which procedure could bring more predictable results, make longer lasting effect, and has minimal risk and morbidity. In my opinion, it is rationally impossible to say that one technique is better than the other. I always try to keep in mind that no two patients are the same, so whenever I do my technique, I try to adjust and adapt my technique according to individual specifications. Among the multiple problems related to aging, there are three distinctive features, which are wrinkles, volume loss, and drooping facial soft tissue. There is no single method for removing these problems. If the wrinkles are the main problem, we can get the best result by facial resurfacing. If somebody has deep wrinkles, fold, and drooping facial soft tissue, I usually perform the extended SMAS facelift. I always do it with local anesthesia. Under the intravenous sedation with ketamine, midazolam, and propofol, I infiltrate 2% lidocaine with 1:80,000 epinephrine along the proposed incision line. Next, the tumescent solution is infiltrated into the face and neck dissection area. A total of 300-400ml of tumescent solution is infiltrated on the both sides of the face and neck. After infiltration, I begin working on the neck area first and then try to solve the facial problems. Different problems require different amount of subcutaneous and SMAS dissection. If the patient's main problem is wrinkle and one has a thin skin, one requires wide skin dissection and extended SMAS technique. If the patient's main problem is wrinkle and one has a thick skin, one requires narrow skin dissection and extended SMAS technique. If the patient's main problem is drooping and one has a thin skin, one requires narrow skin dissection and extended SMAS technique. If the patient's main problem is drooping and one has a thick skin, one requires wide skin dissection and extended SMAS technique. If somebody receives foreign body injection or secondary facelift, I do my procedure in case by case.

Extended SMAS Facelift

In order to solve the problems related to aging faces, new techniques, including various kinds of barbed suture technique, are developing in present time. Although these several kinds of noninvasive or minimal invasive method for aging face have their own indication and barely complications, these procedures would be less effective than the extended SMAS technique used on those of Oriental person. In the face, there are some retaining ligaments, which support facial soft tissue against gravitational change. With aging, the cheek soft tissue anterior to the zygomatic ligament and posterior to the mandibular ligament descends into the plane between the superficial and deep fascia. However, the attached area by the zygomatic and mandibular retaining ligaments are almost unchanged because the ligaments that support facial soft tissue in normal anatomic position i.e, ligaments retain their integrity while the soft tissue around it relaxes. These changes lead to the formation of a nasolabial fold and jowl. I think the most important consideration factor before choosing a certain procedure is to decide which procedure could bring more predictable results, make longer lasting effect, and has minimal risk and morbidity. In my opinion, it is rationally impossible to say that one technique is better than the other. I always try to keep in mind that no two patients are the same, so whenever I do my technique, I try to adjust and adapt my technique according to individual specifications. Among the multiple problems related to aging, there are three distinctive features, which are wrinkles, volume loss, and drooping facial soft tissue. There is no single method for removing these problems. If the wrinkles are the main problem, we can get the best result by facial resurfacing. If somebody has deep wrinkles, fold, and drooping facial soft tissue, I usually perform the extended SMAS facelift. I always do it with local anesthesia. Under the intravenous sedation with ketamine, midazolam, and propofol, I infiltrate 2% lidocaine with 1:80,000 epinephrine along the proposed incision line. Next, the tumescent solution is infiltrated into the face and neck dissection area. A total of 300-400ml of tumescent solution is infiltrated on the both sides of the face and neck. After infiltration, I begin working on the neck area first and then try to solve the facial problems. Different problems require different amount of subcutaneous and SMAS dissection. If the patient has thick facial skin and his or her main problem is drooping, wide skin area and SMAS undermining beyond the retaining ligaments is required. If the patient has thick facial skin and the main problem is wrinkles, less skin area and wide SMAS dissection is needed.