https://orcid.org/0000-0001-8548-8241
Abstract
The mainstream facelifts in Western countries always involve the superficial fascia/superficial musculoaponeurotic system treatment. Meanwhile, subcutaneous face and neck lifts are widely applied among Asians.
The authors sought to evaluate outcomes of subcutaneous face and neck lift, including patient-reported and 3-dimensional (3D) measurement outcomes, and report on details of surgical procedures.
Patients who received a subcutaneous face and neck lift from January 2017 to June 2019 were asked to complete FACE-Q scales, and facial information was collected by the Vectra 3D imaging system preoperatively and postoperatively. Volume changes in midface and possible displacement of facial landmarks were measured. The range of dissection and the amount of skin removed were recorded intraoperatively.
In total, 119 patients (median age, 46 years, interquartile range, 40-53 years) received a subcutaneous face and neck lift. Among them, 88 patients completed pre- and postoperative FACE-Q scales. Patients’ satisfaction with facial subunits improved and wrinkles were significantly relieved (P < 0.001). Nineteen patients (38 midface sides) completed 3D image data collection. Postoperatively, zygomatic volume increased, and nasolabial and lateral cheek volumes decreased (volume change of 2.2 ± 1.3 mL). Mouth, nose, and eye displacements were negligible postoperatively. The widths of skin removed at the middle temporal, front of the sideburns, upper helix, earlobe, and retro-auricular were 13.8 ± 1.9 mm, 19.6 ± 3.1 mm, 27.6 ± 3.9 mm, 16.4 ± 3.9 mm, and 32.2 ± 4.0 mm, respectively.
The authors’ subcutaneous face and neck lift was effective in relieving nasolabial sagging, improving wrinkles, and achieving facial rejuvenation.
Facial aging poses as a major problem in the aging process. The repeated contraction of facial expression muscles results in the formation and deepening of wrinkles, such as forehead lines, glabellar frown lines, nasal root wrinkles, crow’s feet, and others. The soft tissue of the face and neck appears loose and ptotic under the influence of gravity, which results in a deepened nasolabial groove, marionette lines, widened cheek, and a loss of a vivid contour of the neck and jawline. Therefore, reducing facial wrinkles by weakening the muscle of facial expression and increasing soft tissue tightness employing an appropriate lifting technique are 2 principal approaches to achieving facial rejuvenation. When it is difficult to achieve satisfactory results with laser therapy,1 radiofrequency techniques,2 filler injections,3 or minimally invasive surgeries,4 facelift is the ultimate effective method utilized to achieve facial rejuvenation.
Facelift surgical techniques have undergone several modifications since their invention. Initially, the classic concept of subcutaneous facial lift involved modified extensive subcutaneous dissection and removal of redundant skin. In the 1960s, Skoog processed the deep-plane approach to the midface for the first time.5 In the 1970s, Mitz and Peyronie described the superficial fascia/superficial musculoaponeurotic system (SMAS), after which the techniques of folding and suspending the SMAS were widely applied.6 In the 1990s, Hamra made further improvements with his description of the deep-plane rhytidectomy.7 The deep plane of the face is defined as the embryologic cleavage plane separating the superficial soft tissue envelope from the deeper structures of the face bounded by the deep cervical fascia. In recent years, some surgeons have returned to the classical technique. They limit the dissection level to the subcutaneous tissue and include only the SMAS plication procedure.8
There are controversies surrounding the surgical technique in which only subcutaneous dissection is performed. Some surgeons are of the opinion that performing a subcutaneous facelift with or without SMAS plication should be considered for only younger patients or should be employed by surgeons with limited technical capabilities,8 whereas other surgeons propose that elderly patients who have excessive skin laxity may achieve the desired results by subcutaneous rhytidectomy.9
However, through a large number of surgical cases, detailed 3-dimensional (3D) measurement data, and follow-up questionnaires, this study will prove that by the surgical technique of subcutaneous dissection, appropriate skin removal, adequate suspension, and skillful suturing, surgeons can effectively improve looseness and ptosis in the face and neck and achieve significant wrinkle removal and improvement in both younger and elderly patients. In addition, we will provide the exact boundary of subcutaneous dissection and quantify the criteria for skin removal.
METHODS
Patient Information
From January 2017 to June 2019, 119 patients underwent a subcutaneous face and neck lift. All patients were experiencing a natural aging process. Patients who had experienced disease, trauma, or deformity or who had undergone facial bone contouring surgery were excluded from the study. Patients who complained of sagging nasolabial fold, sagging cheeks, unsmooth jaw curve, and widely loose skin; who gave consent to long incisions; and who were willing to improve their appearance were scheduled for this surgery, with or without a previous minimally invasive surgical experience. From January 2017, our team employed a series of FACE-Q scales to evaluate systematically the facial, psychological, and social conditions of the patients pre- and postoperation. A Vectra (Canfield Scientific; Parsippany, NJ) 3D facial imaging device was employed to collect and analyze patients’ facial contours pre- and postoperation. This study was approved by the IRB of Peking University Third Hospital (IRB number M2017364). Written informed consent was acquired from all patients.
Surgical Technique
Patients were placed in the supine position. Local anesthesia and general anesthesia by tracheal intubation were applied. The incision was marked bilaterally with methylene blue, from the temporal hairline to the sideburns, the tragus, the earlobe, the retroauricular groove, along the arc to the mastoid, and then to the occipital hairline. The dissection boundary of the temporal, buccal, neck, and retroauricular areas was marked. The lateral boundary of the dissection was the incision. At the temporal area, the dissection was directed to the interior to the lateral orbital margin. At the zygomatic area, the dissection was directed across the zygomatic arch and zygomatic process and was stopped at 1 cm lateral to the nasolabial. Meanwhile, the zygomatic ligament had fully divided. At the cheek, the dissection ran laterally along the curve of the nasolabial groove. The lower dissection boundary of the neck was 7 to 7.5 cm below the margin of the mandible. Retroauricular dissection included the entire mastoid region anterior to and below the incision. The surgical incision, dissection range, and arrow lines showing the vector of lift on the main landmarks are shown in Figure 1. The estimated amount of skin removed was marked based on our previous experience.
Surgical incision, dissection range, and pulling direction of the main landmarks. The red solid line represents the surgical incision. The purple dotted line and light-yellow area represent the dissection range. The arrow lines represent the lifting direction of main landmarks. Arrow line (A) starts from the lateral canthus to the middle of the temporal hairline. Arrow line (B) starts from the angulus oris to the very front of the temporal hairline. Arrow line (C) starts from the angulus oris to the upper rim of the helix. Arrow line (D) starts along the mandibular edge to the earlobe. Arrow line (E) shows the lift direction of retroauricular region.
Tumescent infiltration, in which 20 mL of 2% indocaine and 0.5 mg epinephrine were added to every 500 mL of saline, was injected along the incision and the dissection area. On each side, 300 to 400 mL of tumescent infiltration was utilized. Incisions were made along the marked lines, dissection progressed in the subcutaneous plane according to the design, and electrocautery was fully performed to maintain hemostasis. Wedge-shaped cuts were made on the lateral orbital part of the orbicularis oculi on both sides to eliminate the contraction of the orbicularis oculi muscle and improve the crow’s feet. The dissected skin flap was lifted superiorly and laterally. The estimated excision points on each marked arrow line were sutured to secure the position and reduce the skin tension. Afterwards, surgeons finely adjusted the actual amount of skin excision from the temporal to the retroauricular area. If necessary, the suture could be cut and readjusted to achieve the best lifting effect. After resection, simple interrupted sutures with 4-0 silk threads were made in the subcutaneous layer, simple interrupted sutures with 5-0 absorbable threads were made in the dermal layer, and the incision was continuously lock-stitch sutured with a 6-0 nylon thread. Fixation of key points before the fine excision and the immediate postoperative suturing effect is shown in Figure 2. To avoid pixie ear deformity, subcutaneous tension-reduced suture was reinforced more intensively in the area above the earlobe and after the earlobe. Also, the earlobe is designed to slightly lean forward and roll in to balance the trend of “pixie ear” during the recovery period, as shown in Figure 3.
Intraoperative photos of this 52-year-old female patient. (A) The preoperative marks on the patient, including the lifting directions and the estimated skin removal amount on each key point. (B) The procedure that skin graft on each key point is lifted and sutured. (C) The state that the actual amount of skin excision of the full-incision is finely adjusted, and the subcutaneous suture has been performed. (D) The final skin suture.
Diagram of the suturing skill to prevent pixie ear. The earlobe is sutured to slightly lean forward and roll in.
A negative-pressure drainage tube was placed bilaterally in the temporal and retroauricular areas for 24 hours. Drainage was removed in 24 hours, the suture was intermittently removed on the sixth day, and all sutures were removed on the eighth day. The actual resection length on each arrow line was recorded. A surgeon can utilize these data as reference to ensure the symmetry and consistency of a bilateral facial lift.
3D Facial Imaging Measurement
Vectra 3D facial imaging acquisition devices and analysis software were employed to collect 3D images of patients pre- and postoperation. After registering the pre- and postoperative 3D facial imaging on the Vectra software, the topographical projection changes (ie, the registration and superimposition of post- and preoperative scans) in the midface were exported. The volume changes in the zygomatic, nasolabial, and lateral cheek regions were measured and recorded. The location sketch of the above 3 areas is shown in Figure 4. The distances between the bilateral cheilion points, bilateral alare points, and bilateral ectecanthion points were measured as L1, L2, and L3, respectively, which are also shown in Figure 4. All data were recorded in Microsoft Excel (Microsoft; Redmond, WA).
A photo of this 58-year-old female as an example. (A-B) The division of the zygomatic, nasolabial, and lateral cheek regions. The blue zone represents the zygomatic, the green zone the nasolabial, and the red zone the lateral cheek region. (C) The diagram of facial landmarks measurement. L1 goes from right angulus oris to left angulus oris, L2 goes from right alare to left alare, and L3 goes from right ectecanthion to left ectecanthion.
Patient-Reported Outcome
A day before surgery and at least after 6 months of the follow-up, patients were asked to complete the FACE-Q scale,10-13 including satisfaction with overall facial appearance, satisfaction with cheekbones, satisfaction with cheeks, appraisal of neck, overall appraisal of lines, appraisal of nasolabial lines, appraisal of crow’s feet lines, and appraisal of marionette lines. They also recorded scales of satisfaction with decision, satisfaction with outcome, social function, psychological function, and age appraisal visual analog scale score. Possible complications and early recovery symptoms were recorded.
Statistical Analysis
All parameters were tested for normality. Data recorded as L1, L2, and L3, and the outcome of all series of FACE-Q scales were not normally distributed. Thus, they were described as medians (interquartile ranges), and the Wilcoxon rank-sum test was applied to compare differences pre- and postoperatively.
RESULTS
Skin Removal
Among the patients recruited, 116 were females and 3 were males, with a median age of 46 years (interquartile range, 40-53 years). The width of skin removed was 13.8 ± 1.9 mm in line A, 19.6 ± 3.1 mm in line B, 27.6 ± 3.9 mm in line C, 16.4 ± 3.9 mm in line D, and 32.2 ± 4.0 mm in line E.
Morphometric Measurements
In this study, 19 patients (38 midface sides) completed Vectra 3D image collection 1 day preoperatively and 6 to 18 months postoperatively. The horizontal length, volume, and topographical projection we measured were all valid according to the validation study on Vectra devices.14 Postoperative volume changes of the zygomatic, nasolabial, and lateral cheek regions in all 38 sides of faces are shown in Table 1. In the topographical projection (Figure 5), there was a trend suggesting volume increase in the zygomatic region, as shown by the green and blue areas. In the nasolabial and lateral cheek regions, the yellow and red areas suggest a volume decrease. The postoperative volume change (ie, volume again in zygomatic and volume decrease in nasolabial and lateral cheek) was 2.2 ± 1.3 mL compared with the preoperative measures.
Postoperative Volume Changes of the Zygomatic, Nasolabial, and Lateral Cheek Regions in All 38 Sides
| Patient number | Zygomatic (mL) | Nasolabial (mL) | Lateral cheek (mL) | Volume change (mL) |
|---|---|---|---|---|
| 1 | 0.7 | −0.4 | −3.5 | 4.5 |
| 2 | 0.5 | −0.3 | −1.7 | 2.6 |
| 3 | 0.2 | −1.2 | −1.0 | 2.4 |
| 4 | 0.2 | −0.6 | −0.2 | 1.0 |
| 5 | 0.1 | −0.2 | −0.1 | 0.4 |
| 6 | 0.1 | −0.5 | −0.1 | 0.7 |
| 7 | 2.3 | −0.4 | −1.6 | 4.2 |
| 8 | 1.9 | −0.3 | −1.6 | 3.7 |
| 9 | 0.4 | −0.7 | −0.3 | 1.4 |
| 10 | 0.3 | −0.7 | −0.2 | 1.2 |
| 11 | 0.3 | −0.6 | −0.2 | 1.1 |
| 12 | 0.3 | −0.7 | −0.2 | 1.2 |
| 13 | 1.2 | −0.3 | −0.2 | 1.7 |
| 14 | 0.9 | −2.5 | −2.2 | 5.6 |
| 15 | 0.3 | −0.2 | −1.3 | 1.7 |
| 16 | 0.2 | −0.1 | −1.0 | 1.3 |
| 17 | 0.5 | −0.6 | −0.1 | 1.1 |
| 18 | 0.2 | −1.9 | −2.0 | 4.2 |
| 19 | 0.1 | −2.1 | −0.5 | 2.7 |
| 20 | 0.2 | −1.9 | −0.4 | 2.5 |
| 21 | 0.6 | −0.1 | −0.1 | 0.8 |
| 22 | 0.5 | −0.8 | −0.8 | 2.0 |
| 23 | 0.8 | −0.2 | −0.4 | 1.4 |
| 24 | 0.8 | −0.1 | −0.4 | 1.2 |
| 25 | 0.3 | −0.9 | −0.8 | 1.9 |
| 26 | 0.3 | −1.8 | −1.0 | 3.0 |
| 27 | 0.3 | −1.1 | −1.0 | 2.4 |
| 28 | 0.3 | −0.7 | −0.1 | 1.1 |
| 29 | 1.1 | −0.8 | −0.2 | 2.1 |
| 30 | 1.0 | −1.3 | −1.1 | 3.4 |
| 31 | 0.5 | −0.5 | −0.1 | 1.1 |
| 32 | 0.2 | −1.0 | −2.1 | 3.3 |
| 33 | 0.9 | −0.6 | −1.5 | 3.0 |
| 34 | 1.1 | −0.4 | −1.1 | 2.6 |
| 35 | 1.0 | −0.3 | −1.2 | 2.6 |
| 36 | 0.9 | −2.5 | −2.2 | 5.6 |
| 37 | 0.6 | −0.3 | −0.9 | 1.8 |
| 38 | 0.4 | −0.3 | −0.3 | 1.1 |
| Patient number | Zygomatic (mL) | Nasolabial (mL) | Lateral cheek (mL) | Volume change (mL) |
|---|---|---|---|---|
| 1 | 0.7 | −0.4 | −3.5 | 4.5 |
| 2 | 0.5 | −0.3 | −1.7 | 2.6 |
| 3 | 0.2 | −1.2 | −1.0 | 2.4 |
| 4 | 0.2 | −0.6 | −0.2 | 1.0 |
| 5 | 0.1 | −0.2 | −0.1 | 0.4 |
| 6 | 0.1 | −0.5 | −0.1 | 0.7 |
| 7 | 2.3 | −0.4 | −1.6 | 4.2 |
| 8 | 1.9 | −0.3 | −1.6 | 3.7 |
| 9 | 0.4 | −0.7 | −0.3 | 1.4 |
| 10 | 0.3 | −0.7 | −0.2 | 1.2 |
| 11 | 0.3 | −0.6 | −0.2 | 1.1 |
| 12 | 0.3 | −0.7 | −0.2 | 1.2 |
| 13 | 1.2 | −0.3 | −0.2 | 1.7 |
| 14 | 0.9 | −2.5 | −2.2 | 5.6 |
| 15 | 0.3 | −0.2 | −1.3 | 1.7 |
| 16 | 0.2 | −0.1 | −1.0 | 1.3 |
| 17 | 0.5 | −0.6 | −0.1 | 1.1 |
| 18 | 0.2 | −1.9 | −2.0 | 4.2 |
| 19 | 0.1 | −2.1 | −0.5 | 2.7 |
| 20 | 0.2 | −1.9 | −0.4 | 2.5 |
| 21 | 0.6 | −0.1 | −0.1 | 0.8 |
| 22 | 0.5 | −0.8 | −0.8 | 2.0 |
| 23 | 0.8 | −0.2 | −0.4 | 1.4 |
| 24 | 0.8 | −0.1 | −0.4 | 1.2 |
| 25 | 0.3 | −0.9 | −0.8 | 1.9 |
| 26 | 0.3 | −1.8 | −1.0 | 3.0 |
| 27 | 0.3 | −1.1 | −1.0 | 2.4 |
| 28 | 0.3 | −0.7 | −0.1 | 1.1 |
| 29 | 1.1 | −0.8 | −0.2 | 2.1 |
| 30 | 1.0 | −1.3 | −1.1 | 3.4 |
| 31 | 0.5 | −0.5 | −0.1 | 1.1 |
| 32 | 0.2 | −1.0 | −2.1 | 3.3 |
| 33 | 0.9 | −0.6 | −1.5 | 3.0 |
| 34 | 1.1 | −0.4 | −1.1 | 2.6 |
| 35 | 1.0 | −0.3 | −1.2 | 2.6 |
| 36 | 0.9 | −2.5 | −2.2 | 5.6 |
| 37 | 0.6 | −0.3 | −0.9 | 1.8 |
| 38 | 0.4 | −0.3 | −0.3 | 1.1 |
Postoperative Volume Changes of the Zygomatic, Nasolabial, and Lateral Cheek Regions in All 38 Sides
| Patient number | Zygomatic (mL) | Nasolabial (mL) | Lateral cheek (mL) | Volume change (mL) |
|---|---|---|---|---|
| 1 | 0.7 | −0.4 | −3.5 | 4.5 |
| 2 | 0.5 | −0.3 | −1.7 | 2.6 |
| 3 | 0.2 | −1.2 | −1.0 | 2.4 |
| 4 | 0.2 | −0.6 | −0.2 | 1.0 |
| 5 | 0.1 | −0.2 | −0.1 | 0.4 |
| 6 | 0.1 | −0.5 | −0.1 | 0.7 |
| 7 | 2.3 | −0.4 | −1.6 | 4.2 |
| 8 | 1.9 | −0.3 | −1.6 | 3.7 |
| 9 | 0.4 | −0.7 | −0.3 | 1.4 |
| 10 | 0.3 | −0.7 | −0.2 | 1.2 |
| 11 | 0.3 | −0.6 | −0.2 | 1.1 |
| 12 | 0.3 | −0.7 | −0.2 | 1.2 |
| 13 | 1.2 | −0.3 | −0.2 | 1.7 |
| 14 | 0.9 | −2.5 | −2.2 | 5.6 |
| 15 | 0.3 | −0.2 | −1.3 | 1.7 |
| 16 | 0.2 | −0.1 | −1.0 | 1.3 |
| 17 | 0.5 | −0.6 | −0.1 | 1.1 |
| 18 | 0.2 | −1.9 | −2.0 | 4.2 |
| 19 | 0.1 | −2.1 | −0.5 | 2.7 |
| 20 | 0.2 | −1.9 | −0.4 | 2.5 |
| 21 | 0.6 | −0.1 | −0.1 | 0.8 |
| 22 | 0.5 | −0.8 | −0.8 | 2.0 |
| 23 | 0.8 | −0.2 | −0.4 | 1.4 |
| 24 | 0.8 | −0.1 | −0.4 | 1.2 |
| 25 | 0.3 | −0.9 | −0.8 | 1.9 |
| 26 | 0.3 | −1.8 | −1.0 | 3.0 |
| 27 | 0.3 | −1.1 | −1.0 | 2.4 |
| 28 | 0.3 | −0.7 | −0.1 | 1.1 |
| 29 | 1.1 | −0.8 | −0.2 | 2.1 |
| 30 | 1.0 | −1.3 | −1.1 | 3.4 |
| 31 | 0.5 | −0.5 | −0.1 | 1.1 |
| 32 | 0.2 | −1.0 | −2.1 | 3.3 |
| 33 | 0.9 | −0.6 | −1.5 | 3.0 |
| 34 | 1.1 | −0.4 | −1.1 | 2.6 |
| 35 | 1.0 | −0.3 | −1.2 | 2.6 |
| 36 | 0.9 | −2.5 | −2.2 | 5.6 |
| 37 | 0.6 | −0.3 | −0.9 | 1.8 |
| 38 | 0.4 | −0.3 | −0.3 | 1.1 |
| Patient number | Zygomatic (mL) | Nasolabial (mL) | Lateral cheek (mL) | Volume change (mL) |
|---|---|---|---|---|
| 1 | 0.7 | −0.4 | −3.5 | 4.5 |
| 2 | 0.5 | −0.3 | −1.7 | 2.6 |
| 3 | 0.2 | −1.2 | −1.0 | 2.4 |
| 4 | 0.2 | −0.6 | −0.2 | 1.0 |
| 5 | 0.1 | −0.2 | −0.1 | 0.4 |
| 6 | 0.1 | −0.5 | −0.1 | 0.7 |
| 7 | 2.3 | −0.4 | −1.6 | 4.2 |
| 8 | 1.9 | −0.3 | −1.6 | 3.7 |
| 9 | 0.4 | −0.7 | −0.3 | 1.4 |
| 10 | 0.3 | −0.7 | −0.2 | 1.2 |
| 11 | 0.3 | −0.6 | −0.2 | 1.1 |
| 12 | 0.3 | −0.7 | −0.2 | 1.2 |
| 13 | 1.2 | −0.3 | −0.2 | 1.7 |
| 14 | 0.9 | −2.5 | −2.2 | 5.6 |
| 15 | 0.3 | −0.2 | −1.3 | 1.7 |
| 16 | 0.2 | −0.1 | −1.0 | 1.3 |
| 17 | 0.5 | −0.6 | −0.1 | 1.1 |
| 18 | 0.2 | −1.9 | −2.0 | 4.2 |
| 19 | 0.1 | −2.1 | −0.5 | 2.7 |
| 20 | 0.2 | −1.9 | −0.4 | 2.5 |
| 21 | 0.6 | −0.1 | −0.1 | 0.8 |
| 22 | 0.5 | −0.8 | −0.8 | 2.0 |
| 23 | 0.8 | −0.2 | −0.4 | 1.4 |
| 24 | 0.8 | −0.1 | −0.4 | 1.2 |
| 25 | 0.3 | −0.9 | −0.8 | 1.9 |
| 26 | 0.3 | −1.8 | −1.0 | 3.0 |
| 27 | 0.3 | −1.1 | −1.0 | 2.4 |
| 28 | 0.3 | −0.7 | −0.1 | 1.1 |
| 29 | 1.1 | −0.8 | −0.2 | 2.1 |
| 30 | 1.0 | −1.3 | −1.1 | 3.4 |
| 31 | 0.5 | −0.5 | −0.1 | 1.1 |
| 32 | 0.2 | −1.0 | −2.1 | 3.3 |
| 33 | 0.9 | −0.6 | −1.5 | 3.0 |
| 34 | 1.1 | −0.4 | −1.1 | 2.6 |
| 35 | 1.0 | −0.3 | −1.2 | 2.6 |
| 36 | 0.9 | −2.5 | −2.2 | 5.6 |
| 37 | 0.6 | −0.3 | −0.9 | 1.8 |
| 38 | 0.4 | −0.3 | −0.3 | 1.1 |
Typical topographical projection of patients after subcutaneous face and neck lift. The yellow and red areas exist typically in the nasolabial and lateral cheek regions, hinting at the obvious decrease in volume.
The outcome of L1-L3 is shown in Table 2. There was no significant change in the distance between the left and right cheilions, which suggested that the perioral structure would not expand due to tension after a large range of skin removal and lifting. After surgery, the bilateral alare points and ectecanthion points were slightly extended, with an average of 0.8 mm (range, 0.3-1.6 mm) on each side of the alare and 1 mm (range, 0.2-2.4 mm) on each side of the ectecanthion.
Outcomes of L1-L3 and P Values of These Pre- and Postoperative Comparisons
| Preoperative (mm) | Postoperative (mm) | P value | |
|---|---|---|---|
| L1 | 52.2 (50.0-52.7) | 51.3 (49.3-52.4) | 0.163 |
| L2 | 33.6 (32.3-34.5) | 35.1 (32.5-37.0) | 0.013a |
| L3 | 91.2 (87.9-95.2) | 93.3 (89.9-97.4) | 0.017a |
| Preoperative (mm) | Postoperative (mm) | P value | |
|---|---|---|---|
| L1 | 52.2 (50.0-52.7) | 51.3 (49.3-52.4) | 0.163 |
| L2 | 33.6 (32.3-34.5) | 35.1 (32.5-37.0) | 0.013a |
| L3 | 91.2 (87.9-95.2) | 93.3 (89.9-97.4) | 0.017a |
aSignificantly different.
Outcomes of L1-L3 and P Values of These Pre- and Postoperative Comparisons
| Preoperative (mm) | Postoperative (mm) | P value | |
|---|---|---|---|
| L1 | 52.2 (50.0-52.7) | 51.3 (49.3-52.4) | 0.163 |
| L2 | 33.6 (32.3-34.5) | 35.1 (32.5-37.0) | 0.013a |
| L3 | 91.2 (87.9-95.2) | 93.3 (89.9-97.4) | 0.017a |
| Preoperative (mm) | Postoperative (mm) | P value | |
|---|---|---|---|
| L1 | 52.2 (50.0-52.7) | 51.3 (49.3-52.4) | 0.163 |
| L2 | 33.6 (32.3-34.5) | 35.1 (32.5-37.0) | 0.013a |
| L3 | 91.2 (87.9-95.2) | 93.3 (89.9-97.4) | 0.017a |
aSignificantly different.
Patient-Reported Outcome
Eighty-eight of 119 recruited patients completed both the pre- and postoperative FACE-Q scales. Of these, 85 were female and 3 were male, with a median age of 45 year (interquartile range, 39-51 years) and a median follow-up time of 11 months (interquartile range, 8-15 months). Pre- and postoperative FACE-Q outcomes and the P value results of the Wilcoxon rank-sum test are shown in Table 3. After undergoing a subcutaneous face and neck lift, every patient’s satisfaction with midface subunits, including satisfaction with the entire face, cheekbone, cheek, and neck, had significantly improved, with median scores of over 90. Also, the nasolabial, marionette, and crow’s feet lines were significantly relieved, with median scores of over 90. In all scales of measurement, patients’ score significantly improved postoperatively (P < 0.001). These patients were highly satisfied with their decision to undergo surgery and with the outcome of surgery, and they also had high scores on social function outcome and psychological function outcome, with a median score of 100, respectively.
The Pre- and Postoperative FACE-Q Scales Outcomes and P Value Resultsa
| Preoperative | Postoperative | P value | |
|---|---|---|---|
| Satisfaction with facial appearance overall | 40 (33-51) | 92 (81-100) | <0.001b |
| Satisfaction with cheekbones | 53 (40-68) | 95 (86-100) | <0.001b |
| Satisfaction with cheeks | 35 (30-47) | 91 (77-100) | <0.001b |
| Satisfaction with neck | 54 (41-66) | 92 (77-100) | <0.001b |
| Appraisal of lines: overall | 43 (35-60) | 93 (83-100) | <0.001b |
| Appraisal of lines: nasolabial | 36 (10-47) | 91 (76-100) | <0.001b |
| Appraisal of lines: marionette | 48 (7-64) | 100 (91-100) | <0.001b |
| Appraisal of lines: crow’s feet | 47 (27-64) | 93 (87-100) | <0.001b |
| Satisfaction with outcome | — | 100 (79-100) | — |
| Satisfaction with decision | — | 100 (86-100) | — |
| Social function | — | 100 (86-100) | — |
| Psychological function | — | 100 (84-100) | — |
| Age VAS score | — | −8 (−10 to −6) | — |
| Preoperative | Postoperative | P value | |
|---|---|---|---|
| Satisfaction with facial appearance overall | 40 (33-51) | 92 (81-100) | <0.001b |
| Satisfaction with cheekbones | 53 (40-68) | 95 (86-100) | <0.001b |
| Satisfaction with cheeks | 35 (30-47) | 91 (77-100) | <0.001b |
| Satisfaction with neck | 54 (41-66) | 92 (77-100) | <0.001b |
| Appraisal of lines: overall | 43 (35-60) | 93 (83-100) | <0.001b |
| Appraisal of lines: nasolabial | 36 (10-47) | 91 (76-100) | <0.001b |
| Appraisal of lines: marionette | 48 (7-64) | 100 (91-100) | <0.001b |
| Appraisal of lines: crow’s feet | 47 (27-64) | 93 (87-100) | <0.001b |
| Satisfaction with outcome | — | 100 (79-100) | — |
| Satisfaction with decision | — | 100 (86-100) | — |
| Social function | — | 100 (86-100) | — |
| Psychological function | — | 100 (84-100) | — |
| Age VAS score | — | −8 (−10 to −6) | — |
aMedian (interquartile range). bSignificantly different. VAS, visual analog scale.
The Pre- and Postoperative FACE-Q Scales Outcomes and P Value Resultsa
| Preoperative | Postoperative | P value | |
|---|---|---|---|
| Satisfaction with facial appearance overall | 40 (33-51) | 92 (81-100) | <0.001b |
| Satisfaction with cheekbones | 53 (40-68) | 95 (86-100) | <0.001b |
| Satisfaction with cheeks | 35 (30-47) | 91 (77-100) | <0.001b |
| Satisfaction with neck | 54 (41-66) | 92 (77-100) | <0.001b |
| Appraisal of lines: overall | 43 (35-60) | 93 (83-100) | <0.001b |
| Appraisal of lines: nasolabial | 36 (10-47) | 91 (76-100) | <0.001b |
| Appraisal of lines: marionette | 48 (7-64) | 100 (91-100) | <0.001b |
| Appraisal of lines: crow’s feet | 47 (27-64) | 93 (87-100) | <0.001b |
| Satisfaction with outcome | — | 100 (79-100) | — |
| Satisfaction with decision | — | 100 (86-100) | — |
| Social function | — | 100 (86-100) | — |
| Psychological function | — | 100 (84-100) | — |
| Age VAS score | — | −8 (−10 to −6) | — |
| Preoperative | Postoperative | P value | |
|---|---|---|---|
| Satisfaction with facial appearance overall | 40 (33-51) | 92 (81-100) | <0.001b |
| Satisfaction with cheekbones | 53 (40-68) | 95 (86-100) | <0.001b |
| Satisfaction with cheeks | 35 (30-47) | 91 (77-100) | <0.001b |
| Satisfaction with neck | 54 (41-66) | 92 (77-100) | <0.001b |
| Appraisal of lines: overall | 43 (35-60) | 93 (83-100) | <0.001b |
| Appraisal of lines: nasolabial | 36 (10-47) | 91 (76-100) | <0.001b |
| Appraisal of lines: marionette | 48 (7-64) | 100 (91-100) | <0.001b |
| Appraisal of lines: crow’s feet | 47 (27-64) | 93 (87-100) | <0.001b |
| Satisfaction with outcome | — | 100 (79-100) | — |
| Satisfaction with decision | — | 100 (86-100) | — |
| Social function | — | 100 (86-100) | — |
| Psychological function | — | 100 (84-100) | — |
| Age VAS score | — | −8 (−10 to −6) | — |
aMedian (interquartile range). bSignificantly different. VAS, visual analog scale.
In the follow-up survey, no patient reported facial discomfort, itching, numbness, stiffness, or uneven skin contour. No patient reported difficulty in facial expression or swallowing. One patient (1.1%) complained of a strong sense of traction after surgery, which gradually disappeared after 6 months. Two patients (2.3%) complained of significant scarring at the preauricular incision. They received local injections of diprosone 3 to 4 times and achieved satisfactory prognosis.
To show that this surgical technique produced good results in both young and elderly patients, 2 typical cases are shown in Figure 6 and Figure 7, respectively. A typical case of a young patient is shown in Figure 6. This patient is a 38-year-old female who complained of upper face wrinkles and midface ptosis. After an endoscopic forehead lift in addition to subcutaneous face and neck lift, the forehead and glabella wrinkles significantly improved and the ptosis in the midface was relieved.15 A volume gain in the midface was visible to the naked eye, and the jawline was clearer. The skin became tighter and smoother because of the skin resection and lifting. The incision scar was well-hidden and acceptable. This patient had sagittal microgenia, to be noted, which is common in Asians, but this does not affect the choice of surgical technique.
The preoperative and postoperative photos of this 38-year-old female typical case. (A-C) Natural expression from the frontal view preoperatively, at 30 months postoperatively, and at 36 months postoperatively, respectively. (D-F) A left 45° side view preoperatively, at 30 months postoperatively, and at 36 months postoperatively, respectively. (G-I) A left 90° side view preoperatively, at 30 months postoperatively, and at 36 months postoperatively, respectively. (J-L) A right 45° side view preoperatively, at 30 months postoperatively, and at 36 months postoperatively, respectively. (M-O) A right 90° side view preoperatively, at 30 months postoperatively, and at 36 months postoperatively, respectively.
Preoperative and postoperative photos of this 62-year-old female typical case. (A-C) The natural expression from the front view preoperatively, at 24 months postoperatively, and at 36 months postoperatively, respectively. (D-F) A left 45° side view preoperatively, at 24 months postoperatively, and at 36 months postoperatively, respectively. (G-I) A left 90° side view preoperatively, at 24 months postoperatively, and at 36 months postoperatively, respectively. (J-L) A 45° side view preoperatively, at 24 months postoperatively, and at 36 months postoperatively, respectively. (M-O) A right 90° side view preoperatively, at 24 months postoperatively, and at 36 months postoperatively, respectively. After the follow-up of 24 months, this patient received blepharoplasty.
A typical case of an elderly patient is shown in Figure 7. This patient is a 62-year-old female who complained of mid- and lower face ptosis and skin laxity. After a subcutaneous face and neck lift, the mid- and lower face ptosis significantly improved. The nasolabial groove was significantly relieved, the marionette line disappeared, and the jawline ptosis was improved.
DISCUSSION
Interpretation of Results
Through the topographical projection, we observed a trend of volume increase in the zygomatic region and a trend of volume decrease extensively below the zygomatic region. To precisely describe this outcome, we measured postoperative volume changes of the midface in 3 parts (zygomatic, nasolabial, and lateral cheek regions), which gave us data to confirm volume addition in the zygomatic region and loss in both the nasolabial and lateral cheek regions. Jacono et al reported a midface volume change after deep-plane rhytidectomy, where a trend of volume gain in the zygomatic region was also observed.16 They did not measure the volume change in the lateral cheek.
Through 3D measuring in a standardized coordinate system based on the Frankfurt horizontal plane, we estimated that the perioral shape, nasal breadth, and periocular shape barely change after a subcutaneous face and neck lift.17 Besides, according to the responses obtained during the follow-up, patients did not think that the above structures were significantly widened.
Through a series of FACE-Q scales, we collected the patients’ subjective evaluation on satisfaction with the middle and lower face and wrinkle severity. All patients’ FACE-Q scores significantly improved postoperatively (P < 0.001), and they had high scores in surgical decision and outcome (median score = 100). The social and psychological function assessments also showed good results (median score = 100). Patients medially felt 8 years younger compared with their preoperative state. Sinno and Gualdi each employed the FACE-Q scales to evaluate the facelift outcome of their extended-SMAS technique and minimal undermining suspension technique, respectively.18,19 The postoperative facial satisfaction and wrinkle scores of these studies were similar to those obtained in our study.
Surgical Concept and Experience
Currently, there are 2 main views on the design of facial rejuvenation surgery. Some surgeons believe that the volume loss and skin descent is the primary contributor to the aging face.20 Therefore, a further increase in the volume of the midface is also necessary while preventing atrophy of the midface through the lifting process.21 Other surgeons believe that midface rejuvenation could be achieved through the facelift technique alone.
The Asian face demonstrates differences in facial structure and cosmetic ideals. Asian faces were typically wider, shorter, and flatter than Western faces.22 After more than 10 years of practice with Asian aging faces, we consider Asian lifting procedures to be indicated for face and neck ptosis, and it is aimed at achieving firmness and a youthful shape. Restoration of volume in the facial subunit, for instance in the medial cheek, and reduction of volume, for instance in the lateral cheek, can assist with forming a precisely youthful shape in Asian cosmetic ideals,21 and these procedures could be achieved together with facelift or secondarily.
Certain techniques could be applied to achieve midface volume restoration. Autogenous fat transplantation and hyaluronic acid filling can help to increase volume.23 In some lifting techniques, the procedure of SMAS plication could restore volume with modified suturing methods.24 Here, we introduce concepts of facial aesthetics, namely “anterior face” and “posterior face.” 25 The compatibility of the anterior and posterior face determines the overall youthfulness and beauty of the face. Procedures such as SMAS plication and lipo-filling restore the volume of the anterior face. Thus, the visual center of gravity is shifted inward and upward, making the face younger and more sculptured. For Asians, who commonly have a flat anterior and wide posterior face, our subcutaneous face and neck lift might decrease the volume of the posterior face by strengthening and lifting the lateral cheek region while also relieving nasolabial sagging. The visual center of gravity can also be shifted inward and upward eventually. This was proven by our topographical projection outcomes.
Some surgeons believe that a subcutaneous facelift could only be an “effective” method for younger patients or for “the surgeon with limited technical capabilities.” 8 However, we hold very different opinions when handling Asian patients. After dissecting the required range of the subcutaneous plane, adequately removing redundant tissue, and properly directing lifting, our subcutaneous face and neck lift achieved a full and lasting facelift effect. During surgery, the direction of lift at the temporal, upper helix, preauricular, and retroauricular regions should be flexibly adjusted and fixed by suturing key points to achieve better practical effects. This procedure was not only suitable for young people but also applicable for a wider population, including older patients and patients with massive weight loss.
The mainstream facelifts with full-length incisions performed recently involve some form of SMAS treatment, including SMAS plication, SMASectomy, and sub-SMAS dissection.26 The SMAS dissection and advancement, in continuity with the platysma, is almost always performed when the platysma muscle is altered in the submental region. However, the aging process among Asians has its own characteristics. Asians have lighter signs of aging in the forehead and glabella wrinkles, nasolabial fold, lower face ptosis, and neck sagging than Caucasians.27 This may explain why the platysmaplasty is seldomly applied in Asian countries. Submental liposuction could be processed at the same time during the subcutaneous facelift for patients with double chin, and the neck contour can be restored. We encourage patients to pursue minimally invasive surgery first. In fact, some of our patients had previously undergone a mini lift. Those patients who did not achieve a long-lasting effect chose our surgical technique as their final attempt.
In previous research assessing facelift outcomes, patients in Western countries tend to receive face and neck lift in older age, at 50 to 80 years as reported by Sinno and 40 to 75 years as reported by Jacono.16,18 Among Asians, patients who wanted to achieve facial rejuvenation were younger, at 35 to 66 years as reported by Ryu28 and 38 to 69 years as reported by Zhang.29 In our study, 74.6% of the patients were younger than 50 years, 19.6% of them were 51 to 60 years, and only 5.8% of them were older than 60 years of age. This corresponds with the fact that Asian patients tend to undergo cosmetic surgery at a relatively younger age. This is also the other possible reason why the subcutaneous facelift technique can meet the needs of Asian patients. If a stable and relatively simple surgery can produce satisfactory results, we do not think it is necessary to pursue technical difficulties. Three patients aged younger 30 years underwent the surgery. They had an extremely high demand on their facial morphology. After being informed of the surgical indications, dissection range, and incision of the surgery, they still requested face and neck lift. Objectively, their facial sagging and skin laxity were slight, so their skin excision was below average.
Patients must be fully informed preoperatively on the choice of incision placement as well as the risk of scars. In early years, we tried both pretrichial sideburn incision and incision below the temporal hairline tuft. These 2 incisions had associated disadvantages. Pretrichial sideburn incision could result in a more obvious incision, but incision below the temporal tuft hairline could result in receding temporal hairline and sideburns, which is obviously not acceptable for Asian patients, especially in male patients.
Asian patients commonly experience more obvious scarring. The patients who received the operation were fully aware of the possible situation of postoperative scarring and the subsequent methods to relieve it. Skillful suturing and appropriate lifting of tension could reduce the intensity of the scarring. According to our follow-up outcome, most of our patients receive the thin linear incision after the operation. Two patients had significant hypertrophic scarring at the preauricular incision. They received local injections of diprosone for 3 to 4 times and achieved satisfactory prognosis.
We made a wedge-shaped cut at the lateral orbicularis oculi to eliminate the contraction of the orbicularis oculi muscle. This step effectively improves crow’s feet according to our graphic follow-up and the FACE-Q scores regarding crow’s feet. About two-thirds of our patients received an endoscopic forehead lift at the same time to comprehensively deal with facial wrinkles (including forehead lines and glabella lines) and to achieve full-face rejuvenation.14
In a recent safety evaluation review, the overall complication rate showed no statistical difference between subcutaneous facelift and sub-SMAS facelift.30 Another systematic review pointed out that lack of homogeneous outcome measures resulted in no reliable meta-analysis on the facelift technique with the best outcome and least complications.31 We believe that there should be different facelift techniques according to the facial and aging characteristics of different populations. With a proven precise effect, no higher risk, and a simpler dissection procedure, the subcutaneous face and neck lift is a suitable and applicable method with definite effects among Asians. Eventually, we hope to introduce an appropriate technique for an appropriate population, rather than arbitrarily praise the superiority of one technology in every aspect.
To prospectively collect pre- and postoperative information of patients and to avoid bias caused by possible unmatured surgical skill, we chose to start this study in 2017 after the invention of FACE-Q scales utilizing our 9-year experience in surgery. The follow-up duration is one of the limitations of this prospective study. In fact, we also set up a retrospective long-term follow-up study in 2017. A total of 126 patients who underwent both subcutaneous face and neck lift and endoscopic forehead lift in 2010 to 2017 with a follow-up of 6 to 86 months had completed the FACE-Q scales, the outcome of which is shown in Table 4. These patients were reported to have satisfactory and consistent performance in midface appearance, neck appearance, nasolabial fold, and facial wrinkles.32 Combining our prospective study in this article and the retrospective study mentioned above, we considered that the subcutaneous face and neck lift achieved satisfactory results in both the medium-term and long-term follow-up. We will continue this prospective follow-up and report further details in the future. Another limitation is the lack of digital scar evaluation. We plan to utilize more intelligent methods to record and evaluate postoperative scarring in subsequent studies.
Retrospective FACE-Q Outcomes of Patients From 2010 to 2017
| Median | Interquartile range | |
|---|---|---|
| Satisfaction with facial appearance overall | 89.5 | 82.0-92.0 |
| Satisfaction with cheekbones | 95.0 | 89.5-100.0 |
| Satisfaction with cheeks | 91.0 | 91.0-100.0 |
| Satisfaction with neck | 88.50 | 79.0-92.0 |
| Appraisal of lines: overall | 87.0 | 83.0-93.0 |
| Appraisal of lines: nasolabial | 91.0 | 83.0-100.0 |
| Appraisal of lines: marionette | 100.0 | 86.0-100.0 |
| Appraisal of lines: crow’s feet | 93.0 | 87.0-100.0 |
| Satisfaction with outcome | 92.0 | 86.5-100.0 |
| Satisfaction with decision | 91.0 | 86.0-100.0 |
| Social function | 89.0 | 82.5-96.0 |
| Psychological function | 91.0 | 83.0-96.50 |
| Age VAS score | −7.75 | −10.0 to −6.0 |
| Median | Interquartile range | |
|---|---|---|
| Satisfaction with facial appearance overall | 89.5 | 82.0-92.0 |
| Satisfaction with cheekbones | 95.0 | 89.5-100.0 |
| Satisfaction with cheeks | 91.0 | 91.0-100.0 |
| Satisfaction with neck | 88.50 | 79.0-92.0 |
| Appraisal of lines: overall | 87.0 | 83.0-93.0 |
| Appraisal of lines: nasolabial | 91.0 | 83.0-100.0 |
| Appraisal of lines: marionette | 100.0 | 86.0-100.0 |
| Appraisal of lines: crow’s feet | 93.0 | 87.0-100.0 |
| Satisfaction with outcome | 92.0 | 86.5-100.0 |
| Satisfaction with decision | 91.0 | 86.0-100.0 |
| Social function | 89.0 | 82.5-96.0 |
| Psychological function | 91.0 | 83.0-96.50 |
| Age VAS score | −7.75 | −10.0 to −6.0 |
VAS, visual analog scale.
Retrospective FACE-Q Outcomes of Patients From 2010 to 2017
| Median | Interquartile range | |
|---|---|---|
| Satisfaction with facial appearance overall | 89.5 | 82.0-92.0 |
| Satisfaction with cheekbones | 95.0 | 89.5-100.0 |
| Satisfaction with cheeks | 91.0 | 91.0-100.0 |
| Satisfaction with neck | 88.50 | 79.0-92.0 |
| Appraisal of lines: overall | 87.0 | 83.0-93.0 |
| Appraisal of lines: nasolabial | 91.0 | 83.0-100.0 |
| Appraisal of lines: marionette | 100.0 | 86.0-100.0 |
| Appraisal of lines: crow’s feet | 93.0 | 87.0-100.0 |
| Satisfaction with outcome | 92.0 | 86.5-100.0 |
| Satisfaction with decision | 91.0 | 86.0-100.0 |
| Social function | 89.0 | 82.5-96.0 |
| Psychological function | 91.0 | 83.0-96.50 |
| Age VAS score | −7.75 | −10.0 to −6.0 |
| Median | Interquartile range | |
|---|---|---|
| Satisfaction with facial appearance overall | 89.5 | 82.0-92.0 |
| Satisfaction with cheekbones | 95.0 | 89.5-100.0 |
| Satisfaction with cheeks | 91.0 | 91.0-100.0 |
| Satisfaction with neck | 88.50 | 79.0-92.0 |
| Appraisal of lines: overall | 87.0 | 83.0-93.0 |
| Appraisal of lines: nasolabial | 91.0 | 83.0-100.0 |
| Appraisal of lines: marionette | 100.0 | 86.0-100.0 |
| Appraisal of lines: crow’s feet | 93.0 | 87.0-100.0 |
| Satisfaction with outcome | 92.0 | 86.5-100.0 |
| Satisfaction with decision | 91.0 | 86.0-100.0 |
| Social function | 89.0 | 82.5-96.0 |
| Psychological function | 91.0 | 83.0-96.50 |
| Age VAS score | −7.75 | −10.0 to −6.0 |
VAS, visual analog scale.
CONCLUSIONS
Through topographical projection, 3D measurement, and patient-reported outcomes, our subcutaneous lift proved effective in relieving ptosis and improving wrinkles in face and neck. Through this procedure, a volume increase in the zygomatic region and volume loss in the nasolabial and lateral cheek regions were achieved, which shifted the visual center of gravity upward and consequently resulted in facial rejuvenation. We also provided an accurate boundary of subcutaneous dissection and quantified the amount of skin resected in each subunit.
Disclosures
The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.
Funding
The authors received no financial support for the research, authorship, and publication of this article.
REFERENCES
