Atlas Oral Maxillofacial Surg Clin N Am 12 (2004) 179197

Correction of cervicofacial deformities

John E. Grifn, Jr, DMDa,*, Bruce N. Epker, DDS, MSD, PhDb
a
Baptist Memorial Hospital Fellowship Program, Cosmetic and Reconstructive Surgery, 300 Hospital Drive,
Columbus, MS 39705, USA
b
Asthetic Surgical Center, 912 South Elm Street, Weatherford, TX 76086, USA

The correction of cervicofacial redundancy via rhytidoplasty is considered the gold standard
of care. The variations of rhytidoplasty techniques proposed by surgeons are almost endless. To
group these variations, the authors categorize them as one of four basic approaches: isolated
meloplication or suspension, S facelifting, traditional supercial plane facelifting, and deep
plane facelifting. Within each of the groupings, variations exist.
This article discusses the S facelift and supercial plane rhytidectomy, because they are
perhaps the most commonly used rhytidoplasty surgical approaches for the correction of
cervicofacial redundancy.
The S-facelift was developed and described by Saylan in 1999 and has been discussed
subsequently in the literature on several occasions. The basic S-lift, as described by Saylan, is
discussed. Some modications that been incorporated into the technique, which makes it more
versatile and enhances treatment results, are covered. The basic indications for the S-lift are (1)
patients with type I to II and possibly III cervical facial laxity, (2) candidates for revision
rhytidoplasty, and (3) smokers.
Type I cervical facial laxity exists in a patient who has minimal redundancy and jowling, no
platysmal muscle abnormalities, slight accentuation of the nasolabial folds, and variable
amounts of cervical facial lipomatosis (Fig. 1A). Type II cervical facial laxity exists in patients
who have notable redundancy and jowling, minimal or no platysmal banding, moderate
nasolabial folds, and variable amounts of cervical facial lipomatosis (Fig. 1B). The type III
patient has moderate redundancy and jowling, platysmal banding, accentuated nasolabial folds,
and variable degrees of cervical facial lipomatosis (Fig. 1C). Type IV does not lend itself to
treatment with the S-lift, even with modications. Patients with type IV have severe redundancy
and jowling, platysmal banding, platysma muscle laxity or dehiscence, severe nasolabial folds,
and variable amounts of cervical facial lipomatosis (Fig. 1D).

S-lift surgical technique

Before surgery, markings are made to outline the approximate extent of the preauricular
excision, the desirable vectors of tightening, the area of undermining in the face and neck, the
location of lipomatosis, platysmal bands, the anterior borders of the sternocleidomastoid
muscle, the inferior mandibular borders, and the thyroid prominence. Local anesthesia with
epinephrine is injected in all lines of planned incision, and tumescent anesthesia is used
(approximately 100150 mL per site; neck, right face, left face).
The S-lift, as described by Saylan, is a short ap rhytidectomy with a preauricular teardrop
excision of skin and subcutaneous tissue, supercial muscular and aponeurotic system (SMAS)
suspension with removal of a dog-ear in the temporal area (Fig. 2). It is rst described as

* Corresponding author.
E-mail address: docgriff@aol.com (J.E. Grifn).

1061-3315/04/$ - see front matter 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.cxom.2004.04.001
180 J.E. Grifn Jr, B.N. Epker / Atlas Oral Maxillofacial Surg Clin N Am 12 (2004) 179197

Fig. 1. (A) Type I cervical-facial laxity. (B) Type II cervical-facial laxity. (C) Type III cervical-facial laxity. (D) Type IV
cervical-facial laxity.

proposed by Saylan, then the modications that were found useful are discussed. The
management of the submental area is not often emphasized when the S-lift is described, but
the operation begins in this area. In almost all of these patients, liposuction, undermining, and,
as indicated, platysmal muscle surgery are performed.
The submental incision is left open until the facial incisions are all completed so at the
completion of the procedure any drainage can be evaluated. The previously marked preauricular
incisions are made and the skin and subcutaneous tissues are excised in the teardrop area. With
a lipo-dissector (4 mm), the extent of the marked short ap is undermined without vacuum.
This aects approximately 75% to 80% completion of the indicated ap undermining, and the
remainder is completed in the traditional fashion with facelift scissors (Figs. 3, 4). Hemostasis is
checked and completed.
SMAS is managed with a primary 2-0 prolene suture, which suspends the platysma at the
mandibular angle area (Fig. 5) to the periosteum of the zygomatic area (Fig. 6) approximately 2
cm in front of the ear tragus. The second suture is placed above this at approximately a 45(
angle from the jowl area and secured to the parotid fascia. The skin ap is then repositioned (eg,
A-A, B-B) with subcutaneous sutures (see Fig. 2). A standard dog-ear procedure is necessary in
J.E. Grifn Jr, B.N. Epker / Atlas Oral Maxillofacial Surg Clin N Am 12 (2004) 179197 181

Fig. 2. Classic S-lift markings and degree of undermining.

Fig. 3. Undermining into neck region for the S-lift.

Fig. 4. Flap elevated for the S-lift.

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Fig. 5. Engaging the platysma muscle.

Fig. 6. Engaging the periosteum of the zygomatic arch.

Fig. 7. Extended undermining of the S-lift ap.

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the hair-bearing area at the superior extent of the incision. Skin closure and facial support
dressings are performed in a standard fashion.
Modications are made to enhance treatment results. They become more benecial as the
severity of the laxity (Types II and III) increases. These modications are (1) submental-
cervical management, (2) incision-excision, (3) subcutaneous undermining, and (4) SMAS
management.

Submental-cervical management

Whenever fat is to be removed, closed liposuction followed by open liposuction is performed,

which mandates that the submental incision be extended for the open liposuction. This
procedure is accomplished with a 6- to 8-inch clear plastic dilatation and curettage suction
cannula. The extended incision (34 cm) also permits direct inspection of the platysmal muscle
and allows for excision of platysmal bands or plication. When repairing or tightening the
platysma, a 2-0 buried prolene suture is used.

Incision-excision

The precise amount of skin excision cannot be determined until the SMAS tightening is
completed. Instead of extending the preauricular incision into the temporal area, it is made from
the superior ear crease inferiorly and anteriorly along the inferior aspect of the sideburn hair.
The incision is beveled to permit hair regrowth into the scar (Fig. 7). After SMAS tightening, the
preauricular skin is redraped, and indicated additional skin is excised (Fig. 8). As with any
rhytidoplasty, this excision should permit the skin ap to rest passively in position without
excessive tension. This procedure is best done incrementally by placing the A-A 1 subcutaneous
suture rst and then adjusting the ap as one progresses superiorly (Fig. 9).

Subcutaneous dissection

The recommended undermining of approximately 5 cm anteriorly and inferiorly, extending to

the sternocleidomastoid muscle and submandibular region, is performed routinely, as described
by Saylan (see Fig. 2). Extension of this ap posteriorly and inferiorly to the ear lobe avoids
bunching of the tissues beneath the ear lobe and allows dog-ear excision in this area when the
skin ap is closed (see Fig. 7). Ease of performing the SMAS tightening also is achieved.

SMAS management

After completing the skin ap and obtaining hemostasis, a lateral SMASectomy, as described
by Baker, is performed. (This procedure is described and illustrated in the following section on
supercial rhytidoplasty.) This procedure may necessitate slightly extending the skin ap for
ideal access (Fig. 10). After completion of the lateral SMASectomy and closure with buried
3-0 prolene suture, the same basic 2-0 prolene vertical neck suspension suture is placed as
previously described from the mandibular angle platysmal muscle to the zygomatic area
periosteum. It is placed inferiorly with a gure-of-eight suture, however, and before securing it
to the zygomatic arch periosteum, a second identical suture is placed anteriorly. Closure of the
skin ap is achieved by redraping and subsequently adjusting with the additional excision
placement of the A-Al subcutaneous suture and performing any indicated additional excision.

The supercial rhytidoplasty

The supercial rhytidectomy is considered the classic operation for Types III and IV patients.
This procedure allows for minimal recovery time and keeps the operative time minimal. More
invasive procedures require a longer convalescence and result in more postoperative edema and
discomfort. Many patients have limited time that they can be away from work, and the selected
procedure must take this into consideration. The authors believe that this procedure provides
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Fig. 8. Repositioning and excising the skin.

Fig. 9. Trimming the ap in an inferior to superior direction.

Fig. 10. Extending the ap and marking the SMASectomy site.

 J.E. Grifn Jr, B.N. Epker / Atlas Oral Maxillofacial Surg Clin N Am 12 (2004) 179197 185

results that are comparable to other procedures and involves much less risk, but the areas of the
neck and jowl must be addressed with special attention.

Procedure

The procedure is usually accomplished in the oce with either intravenous sedation or
general anesthesia. A marking pen is used to indicate the planned incision lines. The manner in
which the preauricular area is marked is determined by the hairline and the amount of temporal
undermining desired. If the surgeon wishes to have an eect on the temporal area, the incision is
marked as demonstrated in Fig. 11. A modication of this incision can be made if the patient
has little hair density in the temporal tuft area or the surgeon wishes to reposition the temporal
tuft (Fig. 12). The preauricular incision also may be designed to preserve the temporal tuft of
hair in its original position (Figs. 13, 14). The posterior auricular incision is made on the conchal
cartilage in women (Fig. 15) and in the crease in men. The submental incision is placed just
posterior to the crease, and a standard tumescence solution is injected into this area rst because
the dissection begins in this region. The solution is injected into the posterior auricular area
next, where it is used to elevate the skin from the cartilage, which aids the dissection in this area
where the ap is thin (Fig. 16). The solution is then placed in the preauricular area.
The dissection begins in the submental area, in which a skin incision is made and a ap is
developed in the subcutaneous plane. A small amount of fat is left on the skin ap to keep the
skin from adhering directly to the muscle, which results in an abnormal appearance (Fig. 17).
The remaining fat is then removed with sharp dissection or liposuction to expose the platysmal
muscle. The platysmal muscle is then engaged with a 3-0 clear nonresorbing suture. The suture is
placed at the site of the new cervicomental angle just off the midline, and another suture is
placed at the same level off the midline (Fig. 18). A pack is placed in this area, and the posterior
auricular area is addressed next.
An incision is made in the posterior auricular area along the previously marked incision line,
and a ap is made in the subcutaneous plane (Figs. 19, 20). The surgeon must exercise caution in
this area, because the ap is thin and perforation is possible. A pack is then placed and then the
surgeon proceeds with the preauricular dissection. A small incision can be made, and the 4-mm
lipo-dissector can be used to undermine the ap before making the full skin incision. An
alternative is to make the skin incision and then proceed with the undermining (Figs. 21, 22).
The undermining should proceed in the submandibular area to the submental region and should
be a continuous ap that allows for the passage of the platysmal suspension sutures to the
mastoid region (Fig. 23). The dissection should remain in the subcutaneous plane and above the
temporoparietal fascia if the ap is developed superior to the zygomatic arch.
The next step is to address the suspension of the muscles. It is believed that a SMASectomy is
the ideal way to manage the SMAS because it creates a smooth eect and places the suspension
in a position that has a greater eect on the nasolabial fold. The SMASectomy is carried from
the angle of the mandible to the zygomatic eminence parallel to the nasolabial fold (Fig. 24).
The area to be excised is marked, and the average excision is 1.5 to 2 cm (Fig. 25). The dissection
should start at the angle of the mandible; a sub-SMAS dissection is initiated, and a pocket is
formed (Fig. 26). The sub-SMAS dissection is continued, and the SMAS is cut as the surgeon
proceeds to the zygomatic eminence (Fig. 27). The segment of SMAS is removed and then
closed with clear 3-0 polydioxanone (PDS) sutures in an interrupted manner (Fig. 28). The area
inferior to the mandibular angle is then suspended to the mastoid fascia with 0 Ethibond sutures
(Fig. 29), which adds further contour to the neck because the SMAS is suspended in this region.
The next area to be suspended is the platysmal muscle in the cervicomental area. The sutures
passed previously are passed under the ap to the mastoid area, where they are secured to the
mastoid fascia with the head slightly turned to the opposite side. This approach ensures that the
suture is not too tight, which results in an unnatural feeling for the patient. The suspension
suture creates a nice angle in the neck as the platysmal muscle is suspended. (Fig. 30
demonstrates the nice angle that is formed with the suspension sutures.)
Liposuction is then performed to freshen the submandibular area and create a smooth
transition to the mental area, where the lipectomy was performed (Fig. 31). The skin aps are
then pulled in a cephalic direction, and the posterior ap is rotated slightly anteriorly (Fig. 32).
186 J.E. Grifn Jr, B.N. Epker / Atlas Oral Maxillofacial Surg Clin N Am 12 (2004) 179197

Fig. 11. Marking the preauricular area with the temporal extension.

Fig. 12. Preauricular area marked with a perpendicular extension to reposition the temporal tuft of hair.

Fig. 13. Preauricular incision marked to preserve the temporal tuft.

This slight rotation helps to prevent a large dog-ear from forming posteriorly. Absolute
hemostasis is obtained, and platelet-rich plasma is then sprayed under the aps. Pressure is held
for 5 minutes while the aps are elevated again and held with the clamps. Two key sutures are
placed initially, one in the preauricular area at the area of the hairline and one posteriorly at the
superior angle of the postauricular incision. 2-0 silk sutures are used for any sutures placed in
the hairline. It is believed that this is much more comfortable for the patient and results in
J.E. Grifn Jr, B.N. Epker / Atlas Oral Maxillofacial Surg Clin N Am 12 (2004) 179197 187

Fig. 14. Preauricular incision deigned to preserve the temporal tuft.

Fig. 15. Posterior auricular area marking for the female facelift.

Fig. 16. Injecting the posterior auricular area.

188 J.E. Grifn Jr, B.N. Epker / Atlas Oral Maxillofacial Surg Clin N Am 12 (2004) 179197

Fig. 17. Submental ap developed.

Fig. 18. Sutures in the platysma muscle for resuspension.

Fig. 19. Incision of the posterior auricular area.

Fig. 20. Posterior auricular ap.

J.E. Grifn Jr, B.N. Epker / Atlas Oral Maxillofacial Surg Clin N Am 12 (2004) 179197 189

Fig. 21. Preauricular incision.

Fig. 22. Incising the preauricular extension.

Fig. 23. Flap developed.

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Fig. 24. Area of the SMASectomy.

Fig. 25. SMASectomy marked.

Fig. 26. Developing the sub-SMAS pocket.

J.E. Grifn Jr, B.N. Epker / Atlas Oral Maxillofacial Surg Clin N Am 12 (2004) 179197 191

Fig. 27. SMAS tissue being excised.

Fig. 28. SMAS repositioning.

Fig. 29. Suspension of the SMAS to the mastoid fascia.

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Fig. 30. Resuspended platysma creating a sharp cervicomental angle.

Fig. 31. Open liposuction.

Fig. 32. Flap repositioning.

 Fig. 33. Anterior extension for inferior repositioning of the temporal tuft.

Fig. 34. Triangular wedge of tissue excised before repositioning the temporal tuft.

Fig. 35. Preoperative view of a Class IIIII patient with jowling and submental laxity.
194 J.E. Grifn Jr, B.N. Epker / Atlas Oral Maxillofacial Surg Clin N Am 12 (2004) 179197

Fig. 36. Preoperative view demonstrating the jowling and submental laxity.

a better cosmetic closure. Drains are not placed with procedures that involve platelet-rich
plasma, but their use is recommended if platelet-rich plasma is not available. The aps are then
adjusted, trimmed, and closed. 5-0 PDS suture is used in the subcutaneous tissue and 6-0 Ethilon
suture in the skin. If a temporal extension incision has been made, care must be taken not to
displace the hairline. An additional incision can be placed and a triangular wedge of tissue
removed to reposition the temporal tuft of hair in an inferior direction (Figs. 33, 34).

Postoperative care

A dressing that provides pressure beneath the ears and relief over the ears in a Barton-type
fashion is placed. The dressing is left in position for 48 hours but can be changed in 24 hours if
the surgeon believes that the surgical site needs inspection. Postoperative steroids and

Fig. 37. Postoperative view of the Class IIIII patient after the modied S-lift.
 J.E. Grifn Jr, B.N. Epker / Atlas Oral Maxillofacial Surg Clin N Am 12 (2004) 179197 195

Fig. 38. Postoperative view of the patient demonstrating the improved neck and jowl area.

antibiotics are used at the discretion of the surgeon. One of the authors uses both, and the other
author uses no antibiotics postoperatively and one dose of Depo-Medrol (methylprednisdone
acetate) intraoperatively. An elastic support dressing is used at night for 1 to 2 weeks, which
protects the ears and incision lines while the tensile strength improves in an area in which there is
loss of sensation and injury is possible. The Ethilon sutures are removed at 1 week and the silk in
the hairline areas at 10 days. The patient is warned of thermal injury with blow dryers and
curling irons until sensation returns to the skin.
The following photographs provide examples of the S-lift and the subcutaneous lift. The rst
case is an example of a Class II or III patient who was treated with the modied S-lift procedure.
(Figs. 35 and 36 show jowling and moderate nasolabial folds.) Submental fat is present with

Fig. 39. Preoperative view of a Class IV patient with signicant platysmal banding.
196 J.E. Grifn Jr, B.N. Epker / Atlas Oral Maxillofacial Surg Clin N Am 12 (2004) 179197

Fig. 40. Preoperative view of severe submental skin laxity and banding.

some skin laxity, but there is no platysmal banding. (Figs. 37 and 38 show the results that were
obtained with the modications that were described.) A SMASectomy was performed, and the
neck was addressed with open liposuction and tightening of the platysma. This result could not
have been obtained in this type of patient with the standard S-lift procedure. The second case is
an example of a Class IV patient who was treated with a subcutaneous procedure. (Figs. 39 and
40 represent a patient with severe skin laxity and platysmal banding.) The jowling is severe, and
the nasolabial folds are exaggerated. (Figs. 41 and 42 represent results obtained with

Fig. 41. Postoperative view of Class IV patient after the subcutaneous lift.
 J.E. Grifn Jr, B.N. Epker / Atlas Oral Maxillofacial Surg Clin N Am 12 (2004) 179197 197

Fig. 42. Postoperative view of patient demonstrating improvement of the neck and jowl area.

a subcutaneous lift, SMASectomy, platysmal suspension, and open liposuction for mandibular
denition.)

Further readings

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Division, Hospital Universitario Pedro Ernesto, 1986, pp. 27986.
Duffy MJ, Friedland JA. The supercial-plane rhytidectomy revisited. Plast Reconstr Surg 1994;93(7):1392403.
Epker BN, et al. Dentofacial deformities: integrated orthodontic surgical approach. St. Louis: CV Mosby; 1996.
Epker BN. Esthetic maxillofacial surgery. Baltimore: Lea and Febiger; 1994.
Ghali GE, Smith BR. A case for supercial rhytidectomy. J Oral Maxillofac Surg 1998;56:34951.
Hamra ST. Composite rhytidectomy. Plast Reconstr Surg 1992;90:111.
Hemrichs HL, Kaidi AA. A subperiosteal face lift: a 200 case, 4 year review. Plast Reconstr Surg 1998;102:84351.
Jost G, Levet Y. Parotid fascia and face lifting: a critical evaluation of the SMAS concept. Plast Reconstr Surg 1984;
74(1):4251.
Mitz V, Peyronie M. The supercial musculo-aponeurotic system (SMAS) in the parotid and cheek area. Plast Reconstr
Surg 1976;38(1):808.
Owley JQ. Lifting the malar fat pad for correction of prominent nasolabial folds. Plast Reconstr Surg 1993;91:4637.
Owley JQ, Flala TGS. Update lifting the malar fat pad for correction of prominent nasolabial folds. Plast Reconstr Surg
1997;100:71521.
Ramirez OM. The subperiosteal rhytidectomy: the third generation face lift. Ann Plast Surg 1992;28:21823.
Sasaki GH, Cohen AT. Meloplication of the malar fat pads by percutaneous cable suture technique for midface
rejuvenation. Plast Reconstr Surg 2002;110:620.
Saylan Z. Purse string-formed placation of the SMAS with xation to the zygomatic bone. Plast Reconstr Surg 2002;110:
66771.
Saylan Z. The s-lift for facial rejuvenation. International Journal of Cosmetic Surgery 1999;7:1724.
Saylan Z. The s-lift: less is more. Aesthetic Surg J 1999;19:406.
Saylan Z. The s-lift is more: my practice to yours. Aesthetic Surgery Journal 1999;19(5):4069.
Stuzin JM, Baker TJ, Gordon HL. The relationship of the supercial and deep facial fascias: relevance to rhytidectomy
and aging. Plast Reconstr Surg 1992;89(3):44151.
Tonnard P, Verpaele A, Monstrey S, et al. Minimal access cranial suspension lift: a modied s-lift. Plast Reconstr Surg
2002;109(6):207486.
Webster RC, Smith RC, Papsidero MJ, et al. Comparison of SMAS plication with SMAS imbrication in face lifting.
Laryngoscope 1982;92:90112.