Answer:
The facelift can be performed in a subcutaneous plane, deep plane (sub-SMAS), both subcut and deep plane, or subperiosteal.
The subcutaneous facelift involves skin undermining to within 1 cm of the lateral orbital rim, across the malar area, up to the nasolabial folds, to a point 1 cm lateral to the oral commissure, and inferiorly over the cervical area. The technique is simplest to perform, with the least risk of injury to the facial nerve branches. It addresses skin laxity, but does not address the tissue deep to the skin.
The SMAS/platysma facelift permits selective alteration of the platysma in the neck and tightening of the SMAS in the cheek. The SMAS is a discrete fascial layer that divides the subcutaneous fat into two distinct layers. It is contiguous with the platysmal muscle inferiorly, the orbicularis oris anteriorly, and the temporoparietal fascia superiorly. The SMAS and the underlying mimetic muscles function as a single anatomic unit in producing movement of the facial skin. The predominant advantage to SMAS tightening is that there is improvement in the jawline. Lateral pull on the SMAS layer accentuates the nasolabial fold.
Deep plane (or extended SMAS) facelift refers to sub-SMAS or deep plane dissection without significant undermining in the subcutaneous plane. The subcutaneous dissection in carried approximately 2-3cm in front of the tragus ending at the jawline. The sub-SMAS plane is dissected in the face medially up to and beyond the nasolabial fold, exposing the orbicularis and zygomatic muscles (the SMAS is transected at the level of the zygomaticus major muscle and the dissection continued in a more superficial plane). This maneuver frees the SMAS from the attached mimetic muscles, allowing the pull on the skin to be transmitted to the fold. The cheek fat is dissected free from the underlying mimetic muscles and is elevated with the skin/SMAS flap. The technique is said to diminish the appearance of the nasolabial fold. The risk of nerve injury may be greater with the more extensive dissection. There is improved vascularity compared to the subcutaneous plane facelift.
The composite face lift attempts to address 3 areas of facial aging: the platysmal muscle of the lower face, the cheek fat of the midface, and the orbicularis oculi muscle, all of which become ptotic. It is an extension of the concept of the deep plane facelift, with the addition of undermining the orbicularis oculi muscle and including it with the cervicofacial flap.
The subperiosteal facelift evolved from craniofacial techniques and the “mask lift” described by Tessier. Through a coronal approach, subperiosteal undermining is carried out around the orbital rims, over the zygomatic arch and body, over the maxilla and down to the piriform aperture. After undermining, the tissue is advanced superiorly and sutured to the temporal fascia. In older patients with skin laxity, the procedure is combined with a preauricular incision. Patients frequently have marked facial edema for several weeks after surgery, and a “mask effect” for several months. Risk of injury to the frontal branch of the facial nerve was high in the initial series, but has been minimized with a deep approach to the zygomatic arch.