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Facelifting is one of the most frequently performed cosmetic procedures in the United States, with numerous techniques having evolved to enable surgeons to address the unique aesthetic and anatomical needs of each patient. Among these, the extended superficial musculoaponeurotic system facelift has gained widespread popularity in recent years due to its long-lasting results and capacity to restore a youthful facial contour by repositioning the ptotic superficial musculoaponeurotic system tissue. Leading facial plastic surgeons have continuously refined this technique, further enhancing its effectiveness and adaptability. This activity provides an in-depth exploration of the extended superficial musculoaponeurotic system facelift, covering each stage of the procedure in detail. This activity also covers topics such as initial patient assessment, selection of appropriate surgical instruments, and a comprehensive, step-by-step explanation of the surgical technique. Operative complications, their prevention, and management are also discussed. Furthermore, this activity highlights the crucial role of the interprofessional team in achieving optimal patient outcomes and providing comprehensive perioperative care for individuals undergoing extended superficial musculoaponeurotic system facelifting. Objectives: Identify the indications and contraindications for using the extended superficial musculoaponeurotic system facelift technique. Improve understanding of facial and cervical anatomy relevant to extended superficial musculoaponeurotic system facelifting. Implement the extended superficial musculoaponeurotic system facelift technique for appropriate patients. Apply strategies to optimize care coordination among interprofessional team members, including facial plastic surgeons, plastic surgeons, anesthesiologists, and perioperative nurses, thus improving outcomes for patients undergoing extended superficial musculoaponeurotic system facelifting and reducing complications. Access free multiple choice questions on this topic.

Facelifting, also known as rhytidectomy, was the third most commonly performed cosmetic surgical procedure in the United States in 2020, following rhinoplasty and blepharoplasty. The popularity of facelifting has remained constant for decades due to the significant impact that facial aging has on self-esteem and perceptions of youth, health, success, and attractiveness.[1] Aging leads to descent of the facial skin and soft tissues, along with lipoatrophy and bony resorption that lead to tear trough deformities, deep palpebromalar grooves, loss of malar volume, descent of the jowls, pronounced nasolabial folds, and development of marionette lines (see Image. Stigmata of the Aging Face). When performed appropriately, facelifting repositions descended soft tissue superiorly to restore facial volume and a more youthful appearance. The earliest described facelifts, as described by Höllander in 1901, involved simple cutaneous excision and skin tightening. Over the past century, techniques have evolved to include simple and extended manipulation of the superficial musculoaponeurotic system (SMAS), mobilization of the malar and sub-orbicularis oculi fat, and minimal access suture suspension options, with each of these methods able to be tailored to the individual patient's needs and the surgeon's expertise.[2][3][4][5] The extended SMAS facelift technique dissects the SMAS more thoroughly and distally than other techniques, providing excellent access to the anterior jawline and neck to reduce jowling, submental fullness, and platysmal banding. Midface rejuvenation may also be achieved by combining extended SMAS dissection with deep plane facelift, wherein ptotic midfacial soft tissue is resuspended superiorly to restore facial volume and create a more youthful appearance.[6][7]

Complications associated with the extended SMAS facelift are similar to those of other rhytidectomies. The most common is patient dissatisfaction with the cosmetic outcome. Other potential complications include postoperative bleeding, hematoma, seroma or sialocele formation, ecchymosis, edema, great auricular or facial nerve branch damage, skin necrosis (see Image. Full-Thickness Necrosis of the Skin Flap), unfavorable scarring, hairline alteration, alopecia, pixie ear deformity (see Image. Pixie Ear Deformity), winged tragus, cobra neck deformity (see Image. Cobra neck Deformity), and depression.[7][18] Hematomas are relatively common, and most can be managed with aspiration in an outpatient setting. However, large and expanding hematomas are best addressed in the operating room (see Image. Upper Neck Hematoma). Men are more likely to develop hematomas than women due to the more robust cutaneous blood supply they possess to support facial hair growth; hypertension is also a major contributing factor, with a systolic blood pressure of >120 to 140 mmHg after surgery more likely to result in postoperative bleeding.[16][23] Effective management of pain, nausea, and vomiting is the most effective means of preventing hematomas after facelifting, even more effective than the placement of suction drains or a compressive dressing.[24]

Although facelifting is a commonly performed procedure, it is time-intensive and demands meticulous execution to achieve the patient's aesthetic goals while minimizing the risk of complications. Permanent motor nerve injuries are rare, but hypesthesia from sensory nerve damage is comparatively common. Bleeding complications, such as hematoma formation, and dissatisfaction with the result or even transient postoperative depression are often encountered as well. The responsibility for preventing adverse outcomes, with respect to the technical aspects of the operation, rests with the surgeon, who must carry out the facelift painstakingly and efficiently. The surgeon is also responsible for identifying medical and psychiatric comorbidities preoperatively and ensuring that any perioperative effects they may have are mitigated to the greatest extent possible or that surgery is not offered. However, even a flawless operation may result in a dissatisfied patient if the patient's expectations were not managed preoperatively. Development of reasonable expectations is a crucial component of counseling, and it is the responsibility of both the patient and the surgeon to engage on the topic and come to an agreement before surgery. Postoperatively, maintaining those expectations is a team effort, shared by the patient, the surgeon, and the clinic nurse. During surgery and in the initial postoperative period, effective communication among the surgeon, anesthesia provider, and nursing staff is crucial for optimizing outcomes and preventing complications. Although fastidious surgical technique and meticulous hemostasis go a long way toward avoiding scarring, asymmetry, nerve injury, and bleeding, maintenance of a low systolic blood pressure and prophylactic treatment for pain and nausea by the anesthesia and recovery room nursing staff have been shown to be the most important interventions in the prevention of hematomas.[23][24]