Point A is the angle of the mandible; B, midpoint; C, lateral canthus; and D, site 4 cm from the mental symphysis. (Used with permission of Mayo Foundation for Medical Education and Research.)
A shows the lines from ear lobes to nasal ala for vertical lift. B, Lines are drawn from the malar eminence to the angle of the mandible for superolateral lift. (Illustration at top of Figure 2A and 2B used with permission of Mayo Foundation for Medical Education and Research.)
The medial edges of the platysma were plicated in each cadaver specimen as shown following application of sutures exerting the superolateral lift.
P indicates superolateral lift with platysmal plication; S, superolateral lift; and V, vertical lift. Squares indicate mean value; bars, 95% CI.
The impact on the degree of platysmal dehiscence (measured in millimeters [x-axis]) as measured in individual cadaver specimens (y-axis) prior to any kind of surgical intervention, following the vertical lift, and following the superolateral lift.
Siwani R, Friedman O. Anatomic Evaluation of the Vertical Face-lift in Cadavers. JAMA Facial Plast Surg. 2013;15(6):422-427. doi:10.1001/jamafacial.2013.1275
This study investigates how different orientations of tension vectors affect the amount of soft-tissue lift in specific cervicofacial regions.
To compare differences in cosmetic neck and face changes generated by 3 different face-lift techniques, to quantify the amount of lift across different points on the face, and to quantify changes in platysmal dehiscence in each of 3 standard superficial musculoaponeurotic system plication face-lift techniques applied to fresh-frozen cadaver heads.
Design, Setting, and Participants
Ten cadaver heads in an academic tertiary care center.
Three different superficial musculoaponeurotic system plication rhytidectomy procedures were conducted in the following sequence: (1) vertical tension vector plication (vertical lift), (2) superolateral tension vector plication (superolateral lift), and (3) superolateral tension vector plication combined with midline platysmal plication (superolateral lift with platysmal plication).
Main Outcomes and Measures
After completion of each technique, the amount of lift at 4 standard key points was measured and recorded, and differences in lift at the key points were analyzed.
Vertical lift was associated with greater total lift than superolateral lift alone or superolateral lift with platysmal plication (P < .001 for both). Platysmal dehiscence increased from baseline measurements after superolateral lift and decreased after vertical lift (P = .002 for both).
Conclusions and Relevance
Our findings establish how different orientations of tension vectors applied during face-lift surgery achieve different structural changes to various key points across the face. This study helps the face-lift surgeon and student understand the underlying structural anatomic changes associated with different face-lift techniques, which ultimately result in different cosmetic outcomes.
Level of Evidence
Early face-lift surgery involved excision and redraping of lax skin.1 Results were encouraging but often short-lived and not ideal because of widening of scars and other shortfalls. Skin-only techniques were the standard surgery for the aging face until 1968, when Tord Skoog,2 of Sweden, realized the importance of repositioning the deeper structures of the face by shifting the platysma in the neck and lower face and the fascia in the cheek. The concept of incorporating the superficial musculoaponeurotic system (SMAS) rather than simply working on the skin has become widely accepted and serves as the foundation for modern face-lift surgery.
Over time, surgical approaches have evolved and been refined, leading to different face-lift techniques, all of which incorporate treatment of the SMAS, including the deep plane face-lift, the composite face-lift, the “SMAS-flap,” the “SMAS-ectomy,” and the “SMAS-plication.”3,4 Regardless of plane of dissection or technique chosen, most of the face-lifts performed until a few years ago had focused primarily on a superolateral vector of pull. In recent years, however, and prompted by a number of newer techniques, such as the minimal access cranial suspension and others, discussions have emerged about incorporating a more vertical vector of pull on the face.5
The objective of the present study was to elucidate the structural anatomic changes obtained at different key points in the face and neck with standard superolateral tension vectors applied to the SMAS compared with application of vertical tension vectors. The goal was to quantitatively measure the amount of lift obtained when the SMAS is repositioned in a superolateral direction and a vertical direction.
This study provides objective measures about how different orientations of tension vectors might affect the amount of soft-tissue lift in specific cervicofacial regions. A more thorough understanding of the underlying anatomic changes associated with the operation may help guide surgeons toward better clinical and surgical decisions and outcomes.
Approval for this study was obtained from the Mayo Clinic institutional review board. Anatomic dissections were completed on 10 fresh-frozen cadaver heads (5 male and 5 female) of persons aged 57 to 85 years. Data on height and weight were collected, as were data from both sides of the cadaver head for each procedure performed, resulting in 20 observations per face-lift technique. Furthermore, we calculated the total lift score as the average of the lift obtained at 4 key reference points. The total lift score represented the amount of lift obtained as a result of each face-lift technique.
Three SMAS plication rhytidectomy techniques were carried out on both halves of each cadaver head in the following order: (1) vertical tension vector (vertical lift), (2) superolateral tension vector (superolateral lift), and (3) superolateral tension vector combined with submental lipectomy and midline platysmal plication (superolateral lift with platysmal plication).
Completing all 3 techniques on the same 10 cadaver heads allowed us to compare the techniques and their effects on the face without concern for the inherent anatomic variability.
A fixation device for the cadaver head was used to maintain consistent position, with the orbitomeatal plane positioned perpendicular to the floor. Before completing the procedures, we noted the presence or absence of redundant cervical skin. Platysmal dehiscence was measured 3 times: before any procedure was carried out, after the vertical lift, and after the superolateral lift. Platysmal dehiscence was calculated as an average of the distance measured between the medial platysma edges at the level of the hyoid bone and at the midpoint between the hyoid bone and the mental symphysis. Obliteration of platysmal dehiscence in the neck after the superolateral lift with midline platysmal plication precluded the assessment of platysmal dehiscence in that group.
Standard face-lift incisions were performed on all cadaver heads. The procedures were completed in the following way. Dissection was carried out in the subcutaneous supra-SMAS layer and extended from the preauricular region to the alar facial crease, nasojugal fold, and corner of the mouth medially. To ensure precise measurement of the soft-tissue face-lift without interference from the weight of the skin, we removed the entire skin flap from the face and neck, with the superior extent limited to the level of the orbital rim.
A line was drawn along the inferior margin of the mandible, stretching from one angle to the other angle of the mandible across the face. To allow for standardization of measurements, we used 4 easily identified points along this line (Figure 1). Point A corresponded with the angle of the mandible. Point C was noted as the point at which a vertical line from the lateral canthus crossed the inferior margin of the mandible. Point B was midway between points A and C. Finally, point D was noted as the point 4 cm lateral to the mental symphysis.
Two parallel lines 1 cm apart were marked from the lower limit of the earlobe to the ala of the nose (Figure 2A). These lines defined the upper and lower limits where suture bites were taken to achieve the vertical face-lift using buried, interrupted, 3-0 braided polyester sutures. Equally spaced, superiorly directed suture bites were taken beginning laterally from the preauricular area and continuing as far distally as possible. The amount of lift achieved was measured by placing 1 end of a caliper at each of the 4 measurement points on the now-raised reference line and placing the other end on the corresponding point on the inferior margin of the mandible. We then measured platysmal dehiscence again at the level of the hyoid bone and at the midpoint. After measurements were taken, the sutures were removed and the tissue was settled back into its original position.
Parallel lines 1 cm apart were marked from the angle of the mandible to the malar prominence (Figure 2B). Sutures were placed in the same manner as in the previous technique by using 3-0 braided polyester sutures in a superolateral orientation. The lateral margins of the SMAS and platysma were also sutured to the mastoid periosteum. Complementary sets of 4 measurements from each side of the face were taken, and platysmal dehiscence was measured.
After completion of the superolateral lift, the sutures were left in place. Subplatysmal fat was removed in specimens as appropriate, and the medial platysmal edges were plicated (Figure 3). A final set of measurements was taken to assess the amount of lift achieved with this technique.
We compared the 3 face-lift techniques by estimating variance components using a linear mixed-effects model based on the measurements and the mean of the 4 points (A-D) noted on the face. The type of face-lift was used for the fixed effect, and the side of the face on which the technique was completed was considered for the random and within-subject effects. In instances in which the type of face-lift was statistically significant, contrast statements were used to complete pairwise comparisons between types. Analysis was completed using commercial software (PROC MIXED component of SAS, version 9.1.3; SAS Institute Inc).
The 2-sided paired t test was used to compare the differences in platysmal dehiscence after the vertical and superolateral lifts. All tests were 2 sided, and P < .05 was considered statistically significant. Analysis was completed using commercial software (JMP, version 7.0.1; SAS Institute Inc).
Preoperatively, we noted that all cadaver heads had redundant facial and cervical skin. During the dissection, we also noted that all the heads had abundant preplatysmal fat and 4 had extensive subplatysmal fat. The 5 male and 5 female cadaver heads had a total mean age of 73.3 years (range, 57-85 years). We collected data on height and weight to calculate body mass index (BMI [calculated as weight in kilograms divided by height in meters squared]) at the time of death. The mean BMI was 23.9 (range, 18.9-29.5).
Data from the face-lifts at all 4 reference points indicated a significant effect by type of procedure (P < .001), with the highest mean for the vertical lift, then the superolateral lift and the superolateral lift with platysmal plication, respectively (Table 1). As reflected in the confidence intervals, little overlap existed among the lifts at points A, B, and C. A degree of overlap was found in the lift obtained at point D between the vertical lift and the superolateral lift.
Point A and point B measurements suggested that all 3 procedures were significantly dissimilar (Table 2). For point C, the vertical lift vs the superolateral lift with platysmal plication and the superolateral lift alone vs the superolateral lift with platysmal plication were significantly dissimilar (P < .001). The comparison between the vertical lift and the superolateral lift also was significant (P = .002).
At point D, the superolateral lift with platysmal plication was significantly different from the vertical lift and the superolateral lift (P < .001 in each case). However, we did not identify a significant difference between the vertical lift and the superolateral lift regarding the measured lift at point D (P = .15).
The effect of the procedure type was significant (P < .001) for the overall lift obtained, with the highest mean for the vertical lift, the second highest for the superolateral lift, and the lowest mean for the superolateral lift with platysmal plication (Table 3). Regarding the total lift, each type of procedure was significantly different (P < .001 in each case) from the other types of procedures (Table 4 and Figure 4).
Platysmal dehiscence significantly decreased by 1.7 mm (P = .002) after the vertical lift and increased significantly by 1.8 mm (P = .002) after the superolateral lift. Figure 5 shows how platysmal dehiscence varied in each head by surgical technique.
The small sample size in our study limited our ability to make statistically significant correlations among BMI, age, and the amount of lift and dehiscence. With that limitation in mind, we found it nonetheless notable that a positive correlation existed between age and dehiscence (r = +0.25) and BMI and dehiscence (r = +0.09). Age and total lift had a positive correlation for each procedure: vertical lift (r = +0.35), superolateral lift without midline platysmal plication (r = +0.34), and superolateral lift with midline platysmal plication (r = +0.22). We noted a negative correlation between BMI and total lift for vertical lift (r = −0.29), superolateral lift without midline platysmal plication (r = −0.06), and superolateral lift with midline platysmal plication (r = −0.04).
The total lift and the lift at all 4 points (A-D) on the face varied significantly by face-lift procedure type (P < .001 for each type of procedure). For each point, we also consistently observed that the highest mean value was for the vertical lift, with the superolateral lift and the superolateral lift with platysmal plication having the next-lowest and lowest means, respectively. Pairwise comparisons between procedures showed that each procedure type was significantly different from the other procedure types for reference points A, B, and C. For point D, no significant difference was found between vertical lift and superolateral lift. Platysmal dehiscence significantly increased after the superolateral lift and significantly decreased after the vertical lift.
Since the first published description of the SMAS layer in 1976 by Mitz and Peyronie,6 the approach to face-lift surgery has been transformed. Surgeons now reposition the SMAS layer and rely on its strength to allow for minimal tension on the skin closure and maximal longevity of the face-lift.7
Various face-lift techniques take advantage of the durability and strength of the SMAS layer to achieve longer-lasting results with minimal wound tension.8- 13 Superficial musculoaponeurotic system plication is one of several techniques used in the manipulation of the SMAS layer to achieve improvement in facial appearance. A controlled study14 involving SMAS plication on one side of the face showed long-lasting effects, with improvement in platysmal cording and in elevation and deepening of the cervical angle.
Our study showed that SMAS plication rhytidectomy with a vertical tension vector yields greater overall lift than the same with a superolateral tension vector. This difference was most notable at the lateral regions of the face, at points A and B. Attenuation of the SMAS layer in the medial cheek area may explain why the vertical lift yielded results comparable to those of the superolateral lift when approaching the midline of the face.
The vertical lift that directly counteracts the effects of gravity has been described as being effective at restoring facial volume that undergoes redistribution during the aging process.15 In contrast, a superolateral tension vector is oriented such that the maximum force is directed toward improving the appearance of the nasolabial fold.
Combining the superolateral lift with midline platysmal plication resulted in a reduction of lift because the medial tension introduced by midline platysmal plication directly opposes the lateral tension provided by the superolateral lift. This brings into question the rationale behind the commonly used surgical technique of platysma plication.
Regarding platysmal dehiscence, the upward pull on the facial tissue provided by the vertical lift brought about an apposition of the platysmal edges. In contrast to the vertical lift, the superolateral lift has the lateral component of pull, which strains the platysmal tissue and promotes dehiscence in the midline. Opposing directions of force are applied to the platysma that theoretically can lead to a lessening of the effects of the face-lift. This pattern has potentially important clinical implications.
This study had limitations characteristic of other anatomic studies. Each cadaver head was subjected to all 3 face-lift techniques. The order of the procedures might have introduced an element of bias, although the procedures were completed such that the technique that theoretically placed the least tension on tissue was conducted first and the one that exerted the most tension was conducted last. However, this process allowed us to directly compare the results achieved with each technique in each cadaver. Confounding factors, such as anatomy, amount of subcutaneous fat, degree of soft-tissue laxity, and strength of the SMAS layer and the platysma, were all matched for each head. In addition, statistical analysis was carried out to account for the correlation among repeated measurements on the same cadaver, allowing measurements on the same side to have a higher correlation than measurements on opposite sides.
Our study has particular relevance to the ongoing evolution of facial rejuvenation techniques. Although modern face-lift surgery offers patients outstanding results, continued efforts to understand the anatomic correlates of aging and of facial rejuvenation allow further refinements of the techniques and improvements in patient outcomes. Our findings show how different orientations of tension vectors achieve different degrees of tissue elevation across the face and lend support to the recent introduction of vertically oriented face-lift techniques.
Accepted for Publication: February 22, 2013.
Corresponding Author: Oren Friedman, MD, Department of Otorhinolaryngology, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19105 (firstname.lastname@example.org).
Published Online: August 22, 2013. doi:10.1001/jamafacial.2013.1275.
Author Contributions:Study concept and design: All authors.
Acquisition of data: All authors.
Analysis and interpretation of data: All authors.
Drafting of the manuscript: All authors.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Siwani.
Administrative, technical, and material support: All authors.
Study supervision: Friedman.
Conflict of Interest Disclosures: None reported.