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    Achieving a superior result with a facelift does not occur by accident. Although there are many techniques in facelift surgery, the basic tenets are to tighten the underlying soft tissues (SMAS and platysma) and the skin, and yet keep a natural, unoperated look. A basic assumption is that the skin will stretch much more than the underlying tissues. What are the techniques that can best achieve this, how can we refine these techniques so the result is predictable and repeatable with fewer complications, and what can we do to make the operation more efficient?

    When approaching a facelift, it is important to make a conscious decision to have a standard routine that you and your staff are familiar with. The more predictable you are, the better your assistance can anticipate your next move. Typically, the clinical vasoconstrictive effects of epinephrine wear of in approximately 2 -2 ½ hours. To decrease post-operative swelling and bruising, the time frame from the injection until closure per side should be under 2 ½ hours.

    The right side of the face is injected with 0.5% lidocaine with epinephrine prior to the prep. After the prep and draping, the left side is then injected. The entire facelift incision is then made. An important point is the angle of slope of the posterior hairline incision, which should start at the junction of the posterior ear and hairline and extend downward at an approximate 45 degree angle (perpendicular to the axis of pull). This will decrease the “jogging” of the posterior hairline. The undermining always begins posteriorly elevating the skin off the adherent section to the sternocliedomastoid musculature. Next, the temporal area is dissected down to deep temporal fascia. The pretragal undermining is then done connecting the posterior dissection to the temporal dissection. The FAME (Aston) technique is utilized when possible to dissect the midfacial area. The temporal mesentery is divided at its superior extent with the FAME technique. This limits the potential for injury of the frontal branches of the facial nerve. The exposure of the neck is now improved, and the remainder of the neck dissection is performed to the midline. An inverted “L” SMAS flap is dissected past the anterior border of the masseter muscle and on the under surface of the platysma muscle into the neck. A small (1-2 cm) back cut is made at the most inferior aspect of the platysma.  A definite release of resistance is felt. The SMAS is then sutured with interrupted, figure of eight 3-0 Vicryl sutures on a SH needle. The neck is then defatted sharply with scissors. The identical procedure is performed on the contralateral side. The submental incision is made and the neck is defatted. A two layer corset platysmaplasty (Feldman) is performed with 3-0 Vicryl. Make sure to take multiple small bites of the platysmal edge. Larger bites of tissue do not increase the strength of the closure and may cause banding. Usually, there is no back cut made in the platysma. The posterior tacking suture is placed with a buried 3-0 Vicryl at the highest point of the post-auricular crease. The post-auricular skin is trimmed and the hair bearing area is closed with staples. A second tacking suture is placed at the anterior root of the ear. The temporal hair bearing skin is trimmed and closed with staples. Based on the height of the sideburn, a small dart of tissue is removed from below the sideburn to prevent the sideburn from riding up. The tissue is then trimmed around the majority of the ear and ear lobe; care is taken so the skin indents the inferior aspect of the ear lobe by 1 mm. A small dart (3-4 mm wide) is taken from behind the ear lobe and closed with a running 5-0 chromic. This adjusts the length of closure between the posterior ear skin and the facial skin. The pretragal skin is defatted aggressively. I almost exclusively use a retrotragal incision in both male and female patients. The final closure is performed with a running, subcuticular 4-0 monocryl suture. A 7 mm Jackson–Pratt drain is placed in the neck before the final closure on the left side. A standard facelift dressing is applied.

    In summary, facelift surgery should be performed with a standard routine in mind so that it can be performed reproducibly and efficiently, and attention to small details will make the surgery a success.