In preparation for the facelift, the patient should be encouraged to stop smoking at least 3 to 4 weeks before the surgery. Patients should also be instructed to hold any anticoagulation if possible before surgery to avoid postoperative hematomas. During the preoperative visit, the plastic surgeon should document any facial asymmetry, as well as the preoperative function of cranial nerves five and seven. Lastly, the patient should be positioned upright to appreciate the features of fascial descent and plan the surgery.

A marker should be used to delineate the path of the intended incisions and flap elevation. Markings are typically physician dependent. Some physicians will mark the zygomatic ligament, the zygomaticus major muscle, the mandibular ligament, and delineate the SMAS. The path of the greater auricular nerve or the temporal branch of the facial nerve can also be marked preemptively to avoid injury during the surgery.[4]

For the extended SMAS technique, the patient should be induced under general anesthesia or deep sedation. The patient should be placed in a supine position, and the surgical table should be rotated if permissible to allow for a more comfortable surrounding around the patient’s face. At this time, the patient’s face and neck should be prepped and draped in a usual sterile fashion. Traditional tumescent may be infiltrated along with the incision sites while attempting to avoid distortion of the tissues. A mixture of 0.25% bupivacaine and 0.05% xylocaine can also be injected in the plane of the intended flap elevation to achieve hydrodissection and hemostasis.

A beveled incision is made with a 10-blade at the temporal hairline to preserve hair follicles; electrocautery in coagulation mode may be used for hemostasis while avoiding hair follicles to prevent hair loss. The incision then travels caudally to a post-tragal incision in females (pre-tragal in males), curves around the ear into the postauricular sulcus, and then along the posterior hairline. Male patients should be informed that post-tragal incisions will bring bearded skin to the tragus, so pre-tragal is the preferred incision.

After the incision is completed, a skin flap is elevated anteriorly towards the cheek, and inferiorly from the mastoid towards the neck; this dissection takes place subcutaneously above the SMAS and third layer. Flap dissection is, on average, 4 cm radially from the inferior aspect of the tragus. Raising this flap too thick may lead to a weak SMAS flap, whereas raising this flap too thin may compromise the vascularity of the skin. Mindful dissection must also be done to not damage the main trunk of the great auricular nerve, which lies above the sternocleidomastoid (SCM) muscle. Jowl fat should be kept on the SMAS, so this can be repositioned cephalad eventually when raising the SMAS flap.[4]

The SMAS is incised horizontally over the zygomatic arch and then caudally, extending from 2 cm anterior to the tragus to just behind the angle of the mandible. At this time, the tissue is undermined through the sub-SMAS plane. Most of the dissection can be carried out with careful spreading of scissors or the Trepsat facial dissectors. Once platysmal muscle fibers are identified, blunt dissection can be performed in the subplatysmal plane; lateral platysmal attachments should be released.

Dissection continues anteriorly in the face over the masseteric muscle releasing the masseteric ligaments. Bichat’s, or buccal, fat pad is usually seen in the anterior aspect of the dissection having an “egg yolk” appearance. Treatment of this fat pad can be done at this time if needed. The dissection is then turned to the zygomatic area. Dissection is performed in the sub-SMAS plane just below the orbicularis oculi muscle and over the distal third of the zygoma to avoid the temporal branch of the facial nerve. Also, care must be observed to stay over the zygoma and avoid its inferior border. The temporal branch of the facial nerves lies about 1 cm anterior to the tragus, and the zygomatic branch runs parallel to the zygomatic arch to innervate the zygomaticus major muscle.

Careful hemostasis with bipolar cautery, if needed, can be done over these areas but is best to avoid. Through this dissection, the zygomatic ligament is released using electrocautery or cold instruments; dissection should stay over the zygomaticus major muscle. From the midface, the dissection should continue inferiorly over the parotidomasseteric fascia to join the previously developed inferior flap. Once conjoined, the flap should be dissected anteriorly until all ligaments are released. When indicated, a submental incision is occasionally used to release the mandibular ligament, perform submental lipectomy, subplatysmal fat dissection, and partial digastric muscle resection. The modiolar peninsula is excluded from the dissection. At all times, an assistant is observing the face for muscle movements in cases where general anesthesia is not used.

After the dissection culminates and proper hemostasis is achieved, the flap can be mobilized and fixated. The SMAS is pulled and attached to the pre-tragal area, and posteriorly to the mastoid periosteum. Polyglactin 2-0 suture is used for suspension. About 10 to 12 sutures are placed on each side, fixating the SMAS and platysma. Careful trimming of the jowl fat and submandibular fat can be performed to enhance the jawline and add volume to the face. The skin must then be checked for dimpling; occasionally, additional supra-SMAS dissection must be done to get rid of these. Excess skin is excised with the 15-blade.

Burrow triangles may need to be created to bring the skin edges appropriately together. The incision is then closed by placing 5-0 prolene on the root of the helix and the cephalad part of the post-auricular incision. The rest of the incisions are then closed with sutures depending on the surgeon's preference. Usually, 4-0, 5-0, or 6-0 absorbable sutures are utilized. Once finished, a topical antibiotic is applied to the incisions, and a compression dressing is placed.[4][8]

Complications of the extended SMAS facelift are similar to other rhytidectomies. These include hematomas, seromas, edema, facial nerve branch damage, transient neurapraxia, unfavorable scars, altered hairlines, pixie ear deformity or deformity of the tragus, wound infections, and deep vein thrombosis (DVT). Hematomas are among one of the most feared complications due to the risk of subsequent flap necrosis, and sometimes even airway compromise.[4]

Each facelift technique must be tailored to a patient’s individual needs. The extended SMAS technique is beneficial for patients who require midface rejuvenation along with the lower face and neck. The firm texture of the SMAS allows for less recurrence, less skin tension, and more stability of the facelift. This technique allows the SMAS to hold in place while the skin overlies the flap without tension. Excess skin that is brought up is then removed. By bringing this layer cephalad, the patient will have increased facial volume, enhanced malar prominence, and a smooth jawline that will lead to a youthful physique and hence increased patient and surgeon satisfaction.

Facelifts overall should be apprehended cautiously; careful assessment by the physician and nursing staff is required. The initial encounter must include a thorough medical evaluation. The physician should be able to determine which facelift technique benefits the patient the most. The patient should be able to understand every risk posed by the surgery, including that of dissatisfaction, even in the setting of a successful facelift. There are times when surgery alone might not be able to achieve the desired result, but fillers or neuromodulators may. A minority of patients might have body dysmorphic disorder or other disorders that warrant expertise evaluation before surgery.

Expectations must be communicated and understood before undergoing a facelift. A well-trained physician will perform a magnificent job under understood expectations and exceptional operating room staff. Post-operative pain control should also be discussed before and after the surgery with the patient and a pharmacist. All of the aforementioned facts will improve outcomes, patient care, and work in the patient’s best interest.