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Aesthetic Surgery Journal (ASJ)
September/October 1999 • Volume 19 • Number 5

The S-lift: Less Is More
Ziya Saylan, MD; Dusseldolf, Germany

The typical superficial musculoaponeurotic system (SMAS) face lift of today involves extensive undermining of facial skin, a potentially lengthy healing time, and risk of complications. The newly repopularized S-lift technique, originally developed in the 1960s, is a more conservative procedure that carries fewer risks of complications. Ideal for both beginning and experienced surgeons who desire natural-looking results with minimal recovery time, the S-lift technique consists of a skin excision at the midface and a modified SMAS plication.

A smaller excision of skin (Figure 1) and a new suspension technique developed by the author can lead to results similar or even superior to those associated with the traditional face lift in the lower face and neck.

Fig. 1. Undemining of the skin during various face lifts. A, skin lift. B, S-lift. C, Face lift with extensive undermining.

The S-lift technique offers many advantages, including a short duration of surgery, a rapid recovery period, more natural results, minimal scarring and hair loss behind the ears and temporal region (Figure 2), and less danger of facial nerve injury.

Fig. 2. An S-formed area of skin is excised. The scar that results from this surgery is acceptable.

Although the S-lift is ideally suited for the younger patient with early laxity of the lower face, it can be used in secondary face lifts and in older patients with lower-face laxity.

Technique
One hundred fifty to 250 mL of tumescent solution is infiltrated into all operative areas with a blunt needle. If necessary, liposuction of the submental region and transmucosal buccal fat pad resection are performed before surgery. If there is separation of the platysma, the muscle is plicated through a submental incision.

The skin is marked (as shown in Figure 3 and 4), and facial nerve blocks and intravenous sedation are used.

Fig. 3. The skin is marked with an S-form before the skin excision.

Fig. 4. Points A and A1, B and B1, and C and C1 are connected during skin closure.

The preauricular area is infiltrated with local anesthetic and tumescent solution to minimize pain and swelling.

After the skin excision, the skin flap is raised (Figure 5) and the SMAS is separated from the subcutaneous fatty tissue.

Fig. 5. The skin is raised.

The use of an extended supraplatysmal plane (ESP) of dissection allows the surgeon to contour and reposition all fat from its deeper layer.1 The dissection extends medially 5 to 7 cm from the tragus.

During this procedure, the masseteric cutaneous ligaments are divided, allowing the surgeon to pull the skin flap separately from the SMAS. While dividing the aponeurotic tissues, the surgeon should keep the dissection inferior to the arcus zygomaticus to avoid major nerve or vessel injury. The dissection should extend inferiorly to the sternocleidomastoid and submandibular regions to allow the platysma, together with the ESP, to be plicated and suspended rather than divided. This technique will supplement correction of the submental angle.

Above the tragus, only skin traction is necessary—ie, pulling from point C to point C1 (Figure 4). The excision should end approximately 2 to 3 cm over the ear (Figure 3) to avoid unnecessary hair loss and a visible scar at the temporal region and to reduce risk of injury to the temporal nerve, which is located deeper in the mesotemporalis region. Although the regional retaining ligaments are released, correction of deep nasolabial folds will not occur, and other techniques, such as excision and fillers, can be used at the same time if necessary.

The SMAS plication (Figure 6) is performed with two sutures of 2-0 Prolene (Ethicon Inc., Somerville, NJ).

Fig. 6. Insertion of the 2 sutures for plication.

The first suture is inserted vertically, beginning at the periosteum of the zygoma and extending inferiorly, small bites being made in the SMAS just anterior to the ear and a good bite being made in the platysma muscle at the mandibular angle. The first suture continues superiorly in a U-shape approximately 1.5 to 2.0 cm anterior to the ear. This suture ends with a bite into the periosteum of the zygoma, being tied firmly but not too tightly; this suture will pull the neck upward. The second suture should be inserted at an angle of 45 degrees to pick up the parotid fascia and SMAS together and pull the lower face sideways and upward. Undermining more than 5 cm away from the tragus toward the midline is not necessary. The suturing is done in an O-shape and performed in multiple small bites.

Fat should not be directly removed from the lower face during the dissection of the supra-SMAS plane. The jowl fat pads can be liposuctioned openly through use of the “vacuum cleaner” technique. Fixation of the fat pad of the hanging cheeks to a higher position at the level of the zygoma usually is advantageous, giving the face a more youthful and natural look.

The skin and subcutaneous vectors should always be positioned 45 degrees superolaterally. The subcutaneous tissues are closed with 3 suspension sutures of 3-0 Vicryl (Ethicon, Inc.), inserted at points A, B, and C (Figure 4), beginning with the lowest point of the skin defect (point A). The suture is placed between the lowest level of the excised part and the tragus (point A to point A1 in Figure 4), the skin being pulled upward and backward under slight tension. The second suture is placed between the medial skin flap at the level of the tragus and the superior helix (point B to point B1 in Figure 4). The third and final suture is placed between the level of the helix of the medial flap and the temporal region (point C to point C1 in Figure 4). After the excess has been trimmed, the remainder of the skin is closed with a 5-0 Prolene continuous suture.

In some cases, dog-ears may develop at the lobe of the ear and in the temporal region. If this occurs, the skin excisions are extended and the dog-ears are removed. Suction drainage after surgery is not necessary. An elastic bandage called “The Wrap” (Byron Medical, Tucson, AZ) is applied to the head for 3 to 5 days.

Complications:
Among a group of 34 patients, 1 case of facial nerve palsy was reported in a patient with a secondary S-lift, but this condition resolved with time. Two patients developed hematomas, one of which had to be aspirated. No instances of skin necrosis or infection were reported. Five patients complained of tension and pain in the pretragal area, but their symptoms disappeared after 3 weeks. Temporary soft tissue dimpling, inferior to the earlobe, occurred in most patients between 8 and 12 weeks after surgery.

Summary:
Best suited to younger patients, the S-lift is a safe, quick, and simple procedure with highly satisfactory aesthetic results. This technique offers minimal complication rates and a brief recovery period, with less scarring than the conventional face lift (Figure 7).

Fig. 7. A, Preoperative view of a 47-year-old patient. B, Postoperative view at 18 months after S-lift procedure.

As plastic surgeons, we tend to believe that the more we do, the better the results. In the surgical treatment of the lower face and neck, it may well be that “less is more.”

Reference
1. Hamra ST. The composite rhytidectomy. Plast Reconst Surg 1992;90:1–13.MEDLINE
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