Composite Facelift Treatment & Management

Updated: Nov 22, 2021
  • Author: Elizabeth Whitaker, MD, FACS; Chief Editor: Deepak Narayan, MD, FRCS  more...
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Surgical Therapy

Deep-plane rhytidectomy initially involves a limited subcutaneous elevation. In the lower face, a sub–superficial musculoaponeurotic system (SMAS) dissection is then developed, elevating the skin, subcutaneous fat, and platysma as a unit. [27, 28] In the midface, a deep subcutaneous plane extends to expose the orbicularis and zygomaticus muscles, freeing the malar fat pad from its deep attachments. In the midface region, the skin, subcutaneous fat, malar fat pad, and platysma are elevated as a unit.

Composite rhytidectomy additionally addresses the orbicularis oculi muscle. Through a lower blepharoplasty incision, the orbicularis oculi is elevated off the malar prominence. This frees the muscle of its attachments to the malar eminence, allowing mobilization and repositioning. As originally described, this dissection plane is then connected to the deep-plane dissection by an incision made between the inferior lateral border of the orbicularis oculi and the zygomaticus minor muscle. A distinct division between these muscles is not always present because they lie in the same plane. This maneuver prevents inadvertent elevation of the zygomaticus minor muscle into the composite flap. The inferior aspect of the orbicularis oculi muscle is trimmed, and the muscle is repositioned in a superomedial vector.

Hamra has since described the zygorbicular dissection as a modification of the composite rhytidectomy technique. [29] The zygorbicular dissection preserves the attachment of the orbicularis oculi and zygomaticus minor muscles. The suborbicularis oculi dissection is carried under the medial portions of the zygomaticus minor and major muscles, leaving some soft tissue overlying the periosteum. This zygorbicular dissection leaves a bridge of tissue between the suborbicularis dissection and the deep-plane dissection in which the zygomaticus muscles lie. Hamra describes less malar edema and chemosis with this modification. [29]


Preoperative Details

Give patients extensive instructions for both preoperative and postoperative care. If the patient smokes, instruct him or her to cease using tobacco or any form of nicotine for at least 2 weeks before and after surgery. Patients who are unable to stop smoking are at significantly increased risk of postoperative complications and healing problems.

Also instruct patients to avoid any medications, supplements, or herbs with anticoagulant effects for 2 weeks prior to surgery and postoperatively. Taking multivitamins and high-dose vitamin C supplements is encouraged. However, high-dose vitamin E supplementation should be avoided because of its potential effect on coagulation.


Intraoperative Details

As with other rhytidectomy techniques, the procedure can be performed under local anesthesia with intravenous sedation or general anesthesia. Preoperative doses of an intravenous antibiotic (usually cefazolin [Ancef], unless the patient is allergic to penicillin) and dexamethasone (unless medically contraindicated) are administered.

Pull the hair back off the face and secure it. Then mark incision lines. Use local anesthesia to infiltrate the incision lines and the area of dissection in a radial fashion from the preauricular region. If performed in conjunction with upper facial rejuvenation procedures (ie, forehead lift, blepharoplasty), perform these prior to the rhytidectomy procedure.

Incision placement varies and depends on technique, patient anatomy and hairline, and surgeon preference. In this description, the temporal incision is marked in a curvilinear fashion, just within the temporal hairline and just superior to the ear. It curves posteriorly to the superior aspect of the helix. This avoids any loss or elevation of the temporal hairline. Then mark the preauricular incision in the natural crease at the junction of the auricle and the face, following the curve of the helical root. The incision can then be either continued in the pretragal crease or carried behind the tragus. See the image below.

Position of the zygomaticus major muscle diagramme Position of the zygomaticus major muscle diagrammed.

The inferior aspect of the incision is located at the junction of the earlobe and cheek. It then curves posteriorly and superiorly into the postauricular area, following the postauricular crease. The incision then curves gently into the occipital hairline at the level of the inferior crus of the antihelix. This occipital incision roughly approximates a line bisecting the angle created by the hairline and a posterior extension of the Frankfort horizontal plane. This incision placement helps prevent a step-off deformity of the posterior hairline.

Flap elevation proceeds in a subcutaneous plane in the preauricular and temporal regions. Take care to elevate in a plane deep to the hair follicles to help prevent hair loss. Too deep a plane in the temporal region may place the temporal branch of the facial nerve, which runs in the temporoparietal or superficial temporal fascia, at risk. "Backlighting" the flap can help maintain the proper dissection plane. See the image below.

Incision made in the superficial musculoaponeuroti Incision made in the superficial musculoaponeurotic system.

Elevation continues anteriorly until the lateral aspect of the orbicularis oculi muscle is reached. Then elevate the postauricular portion of the rhytidectomy flap in a subcutaneous plane, again with care to preserve the hair follicles. Carefully elevate the cervical portion of the flap over the sternocleidomastoid muscle to avoid injury to the greater auricular nerve. Anteriorly, identify the posterior border of the platysma muscle and elevate the flap in a preplatysmal plane under direct vision using vertical spreading motions. This allows cauterization or preservation of any perforating vessels. The dissection is limited superiorly by the inferior border of the mandible and inferiorly by the hyoid bone. The preplatysmal plane serves to protect the marginal mandibular nerve as it courses below the mandible.

With the rhytidectomy flap elevated, turn attention to the deep-plane dissection. Enter the deep plane via an incision made in the SMAS extending from the junction of the body and the arch of the zygoma to just anterior to the angle of the mandible. Initially, perform dissection just beneath the SMAS, starting just superior to the mandible and continuing superiorly. The parotideomasseteric fascia is left intact just below the dissection plane, protecting the facial nerve branches. The dissection can be performed using either a No. 10 blade or scissors with a vertical spreading action. See the image below.

Developing the deep-plane portion of the dissectio Developing the deep-plane portion of the dissection.

Dissection continues anteriorly, ending just lateral to the nasolabial fold. Superiorly, the lateral and inferior portions of the orbicularis oculi muscle have already been identified, marking the superolateral aspect of the deep dissection. Identify the fibers of the zygomaticus major slightly deeper and inferior to this, traversing the midface in an anteroinferior direction. The dissection plane remains superficial to the zygomaticus major muscle and extends inferiorly to the corner of the mouth (modiolus). Sharp division of zygomatico-cutaneous ligaments penetrating the area of the malar fat pad allows full mobilization of the skin and soft tissue, facilitating redraping of the malar fat pad over the malar eminence. See the image below.

The zygomaticus major muscle is visualized, defini The zygomaticus major muscle is visualized, defining the plane of the dissection.

The end result of this dissection is a musculocutaneous flap resulting from deep-plane dissection in the midface and a preplatysmal dissection in the cervical region. See the image below.

The deep plane is developed, creating a composite The deep plane is developed, creating a composite flap.

If indicated for addressing the submental and cervical regions, make a submental incision measuring approximately 2 cm parallel and just behind the submental crease. This allows excellent scar camouflage without deepening the submental crease. Through this incision, chin augmentation can also be performed if indicated.

Carry the dissection through the skin and subcutaneous tissue, identifying the platysma muscle. Then elevate the flap in a preplatysmal plane down to the level of the thyroid cartilage. This central pocket is connected with the bilateral preplatysmal dissection performed in elevating the cervical skin flaps. Cervical lipectomy can be performed under direct vision using this technique, allowing precise sculpting. Grasp the medial edges of the platysma in a clamp and excise the excess.

Then suture the medial edges of the platysma muscles together with interrupted buried 3-0 Prolene sutures. At the close of the rhytidectomy procedure, this incision is closed in 2 layers, with a deeply buried subcutaneous layer followed by a vertical mattress skin closure.

With all aspects of the dissection complete, turn attention back to redraping the skin and soft tissue. Advance the posterior border of the platysma muscle, bridging the sub-SMAS dissection plane of the midface and the preplatysmal dissection of the cervical region, and suture this in a posterior superior direction. Redraping of the flap continues superiorly into the midface. Advance the posterior border of the incised SMAS in a posterior and superior vector, and suture it to the remaining preauricular SMAS layer.

Use buried interrupted 3-0 Prolene sutures and place firm tension on the SMAS closure. Usually a total of 5 or 6 sutures is required. This results in some overlap of the SMAS in the preauricular region. If this is excessive or produces significant bulk, some trimming of the SMAS can be performed; however, this is not usually necessary. Redraping of the composite flap in this manner helps restore the malar fat pad to its natural position, restoring the youthful fullness of the malar eminence and thereby rejuvenating the mid and lower face. With the SMAS closure complete under tension, the excess skin already overlaps free of any skin tension.

Subcutaneous elevation is extended slightly anteriorly only if any dimpling of the skin is present after reapproximation of the SMAS. The skin is also advanced in a posterior-superior vector. Redraping of the skin closure begins at the ear lobule. Make a stab incision in the anterior skin flap at the level of the lobule, and place tacking suture of 5-0 Prolene. Take care to reposition the lobule in a natural position and avoid inferior displacement, which can result in an operated look. Excise excess temporal and preauricular skin free of any tension. If a posttragal incision is used, thin the skin advanced to overlie the tragus to prevent bulking of the tragal appearance. In the postauricular region, the primary advancement of the flap is in a superior vector, and excess skin is excised with care to reapproximate the posterior hairline, avoiding any step-off.

Drains can then be placed bilaterally. Close the hair-bearing portions of the postauricular and temporal incisions with staples. Close the remaining incisions with 5-0 Prolene. Of note, excise excess skin in a tension-free manner so that no significant skin separation occurs prior to suture closure. This minimizes skin tension at closure, allowing optimum healing and minimizing the risk of scar widening and hypertrophy.

With the composite rhytidectomy, the orbicularis oculi muscle is elevated off the periosteum of the malar eminence through a lower blepharoplasty subciliary incision. The inferior margin of the orbicularis oculi muscle can be excised off the flap. After closure of the facelift portion of the dissection, suture the orbicularis oculi muscle to the periosteum of the lateral orbital rim in a superomedial vector.

The approach to dressings and drains varies among surgeons. Some use drains or dressings only, and some use both. In the described approach, antibiotic ointment is placed over the incisions, followed by a nonadherent dressing. A soft cotton pressure dressing is then placed and wrapped with 3-inch Kling gauze dressing. Drains are placed on bulb suction and are usually removed on postoperative day 1. If the procedure is performed under general anesthesia, manual pressure is held on the dressing until the patient is extubated; this helps minimize any possibility of hematoma formation.


Postoperative Details

When used, drains are left in overnight. Take down the dressing and remove the drains on the first postoperative day. Then place a lighter dressing.

Carefully instruct patients to engage in only minimal activity. Strenuous activity must be avoided for at least 2-3 weeks after the surgery. Any medications or herbs with anticoagulant effects also must be avoided. Provide patients with appropriate analgesic medications. Patients remain on antibiotics for approximately 7 days.



If permanent preauricular sutures are used, remove them early, after 3-5 postoperative days. The area of the incision can then be reinforced with adhesive and paper tape. Remove postauricular sutures and staples after 7 postoperative days. These incisions can be taped similarly. The tape can be left in place for 1-2 weeks.

Observe patients closely in the initial postoperative period to monitor for any signs of hematoma formation or infection. The incisions are also monitored over time. If any evidence of hypertrophic scar formation is found, triamcinolone (Kenalog) injections of the scar can be initiated.




Hematoma is the most common complication of rhytidectomy, occurring in as many as 15% of facelift patients. [30] Most hematomas are small, inconsequential collections, which may resolve of their own accord. More discrete collections may require aspiration. In contrast, large, expanding hematomas are emergencies that require imminent drainage. Fortunately, these are much less common, occurring with at an incidence rate varying from 0.9-8% in the literature. These usually occur in the first 6-8 hours after surgery, with signs and symptoms including pain, swelling, and ecchymosis. The dressing should be removed immediately, and the patient should be taken to the operating room to evacuate the hematoma and explore the wound. If any significant time delay occurs before operating room access is possible, then the incision should be opened at the bedside and the clot should be removed to avoid compromising flap viability. The wound can then be explored subsequently when conditions permit.

Studies suggest that postoperative bleeding is a greater risk in male patients than in female patients. Baker suggests this may be due to the increased vascularity of the beard. [9] Other studies have found increased risk of hematoma formation with postoperative hypertension. Therefore, adequate pain control in the postoperative period is important. With deep-plane dissections, hematoma formation may be less frequent because of the thickness of the flap, the minimal subcutaneous undermining, and the tension placed on the flap with closure.


The incidence rate of wound infection with rhytidectomy is low (generally < 1%) because of the excellent blood supply of the head and neck. The predominant organisms causing infections are staphylococcal species. When wound infections occur, they should be treated promptly with antibiotics and with drainage and wound care if indicated.

Skin necrosis

Due to the excellent vascularity of the composite flap, the risk of skin loss is lessened with this technique. However, wound healing problems are significantly more common in patients who smoke, and vascular compromise of the flap is possible. Unrecognized hematoma can also predispose to skin necrosis. Skin slough is generally managed conservatively with debridement and moist or occlusive dressings. The wound is allowed to heal by secondary intention. Scar revision can then be performed at a later date if indicated.

Nerve injury

Rates of facial motor nerve injury vary in the literature from 0-3.3%. In a review of 6551 rhytidectomy procedures, Baker and Conley found a 0.7% incidence of facial nerve injury; most were temporary and resolved in 6 months. [31] In their report, the incidence of permanent injury was 0.1%. [31] Sensory nerve injuries were more common, with injury to the greater auricular nerve reported at a frequency rate of as high as 7%. [31]

A literature review by Jacono et al found that among SMAS facelift techniques, temporary nerve injury rates were highest for the high lateral SMAS flap and composite procedures, at 1.85% and 1.52%, respectively. The various techniques, which also included the SMAS plication, SMASectomy/imbrication, SMAS flap, and deep plane procedures, did not significantly differ with regard to permanent nerve injury risk. [32]


Temporary alopecia is more common than permanent alopecia. It may result from excessive tension on the suture line. Recovery generally occurs over weeks to 6 months. If alopecia is permanent, it can be corrected with local flaps, micrografts, or minigrafts.


Hypertrophic scarring occurs most commonly in the postauricular area or in areas of skin slough. True keloids are rare. Predisposing factors for hypertrophic scarring or keloids include ethnicity, skin type, and family history. Excess tension on suture lines should be avoided because this may predispose to widened or hypertrophic scars. Intralesional steroid injections, frequently serial, can result in significant improvement in hypertrophic scars. Topical silicone therapy has also been described as a treatment.


Outcome and Prognosis

Deep-plane and composite rhytidectomy techniques can produce excellent results in aging changes in both the lower face and midface. However, postoperative edema, particularly in the midface region, is more prolonged with this technique, and patients should be cautioned of this. Deep-plane and composite rhytidectomy techniques create a harmonious rejuvenation, particularly when combined with rejuvenation of the upper face, producing a natural appearance as youthful contours are restored to every area of the face.

A study by Jacono et al indicated that vertical-vector deep-plane rhytidectomy offers a long-term increase in midface volume. Using three-dimensional imaging software on 43 patients (86 hemi-midfaces) at minimum 1-year follow-up, the investigators found that each hemi-midface had gained an average of 3.2 mL in volume. [33]

A study by Ghassemi et al indicated that the deep-plane dissection and composite facelift procedures can be used to replace facial tissue lost to tumor excision, trauma, or congenital malformation. The study involved 47 patients with facial defects of 2-8 cm in diameter in whom the deep-plane/composite facelift procedures were performed. The investigators found no significant lower eyelid, nose, or lip deformities and determined that all patients retained full facial nerve function. They also reported that most of the surgical scars could be hidden and had become undetectable a year after surgery. [34]


Future and Controversies

Debate is found in the literature about the advantage of deep-plane techniques over more conservative rhytidectomy techniques in long-term results and outcome. Discussion is also ongoing about potential increased risk of facial nerve injury with deep-plane dissections. The proponents of deep-plane techniques have demonstrated excellent long-term outcomes, with complication rates comparable to those of other techniques in the literature.

Subperiosteal techniques have also been developed to address the problem of midface ptosis and the melolabial fold. These techniques elevate the periosteum off the zygomatic arch and anterior face of the maxilla to reposition the skin, malar fat, fascia, muscle, and periosteum. While improving the midface, this technique alone does not address skin and soft tissue laxity of the lower face and neck.