There are two well delimited anatomical areas at face and neck in connection with aging and rejuvenation surgery, which have to be addressed separately; the midline or central structures, formed by eyelids, nose, lips and chin; all these indeed do age and deserve specific surgical attention with techniques designed and developed to their anatomical features; and then the peripheral unit made of three thirds of head and neck, being the upper third formed by the forehead, eyebrows, temple and periorbital area, the middle third by cheekbones, cheeks, nasolabial folds and perioral area, and the lower third integrated by the parotid area, the lower area at the jawline and finally the jowls extended into the neck region; these peripheral three thirds can be treated subdivided into two groups; the surgeon may treat the upper two thirds, by means of a short temporal incisions supraperiosteal extended lift of the upper two thirds of the face, or treat the lower two thirds with a deep plane SMAS platysma face and neck lift.
There exists a critical distinction between the face and neck surgically treatable aging effects on the skin, on the fat tissue and on the deep structures; the first idea coming to mind when talking about aging is the skin excess, which has to be necessarily removed during a cervicofacial facelift, and actually many patients and surgeons stay on the surface of aging leading to poor or bad results after rejuvenation procedures; a deeper understanding of face and neck aging is essential, since structures other than merely the skin require the main attention during face and neck lifts.
A modern and complete rejuvenation cervicofacial facelift begins with and includes as first stage during its execution the so called traditional subcutaneous or superficial facelift, in which by means of the traditional pre, peri and retroauricular incisions the skin of the face and neck is undermined, massively and entirely undermined to prevent lateral sweep deformities, pixie ears, pulled tragus, etc, thus allowing both full access to deep facial structures and perfect adjustment of the cutaneous cover without any remaining spare skin left; many surgeons end the procedure at this point or even prior to it when they perform limited subcutanous facelifts, mini facelifts or procedures in short time and under local anesthesia, something absolutely unadvisable.
Then the subcutanenous adiposity of aging has to removed, by means of direct precision shaving rather than by blunt liposuction, to defat the neck, the jowls and tailor an outlined mandibular contour.
Once this is finished comes the deep plane maneuvers, those really requiring top class skills and training, as well as very good dissection skills. One anatomical concept is key here; the platysma muscle of the neck is a thin sheet extending from the corner of the mouth down to the collar bones, so when it ages forms the jowls and the vertical neck or turkey bands; when this muscle ends at the lower third of the face it actually does not, just loses its muscular fibers and becomes a tendinous or fibrotic layer of tissue called SMAS (superficial muscular aponeurotic system) or facial fascia, a key structure to perform the deep plane facelift; this SMAS spreads between the mouth and nose in the midline, the ear at the side, the orbit above and the platysma below; above the SMAS we have the skin and subcutaneous fatty tissue, actually the subcutaneous dissection in the traditional facelift or aforementioned first stage is carried out directly above the SMAS; the SMAS continues above the cheekbone level into the forehead and temple, being exactly the same structure but acquiring new names and composition, like the forehead frontalis muscle and the superficial temporal or temporoparietalis fascia at the temple, which are the same layer than the SMAS.
The SMAS and the platysma muscle play a great role in this surgical procedure; to begin with the surgeon will use the middle third or face SMAS to hold up, tighten and rejuvenate the whole deep facial structures; for this purpose the SMAS has to be elevated and freed with great care from deep functional structures like the parotid gland, the facial nerve and the mimic muscled, and then some modality of plasty, flap and fixation has to be applied, being the standard one the so called Connel's flaps which are 3 vectors, one ascending anchored at the lower orbit, one oblique fixed near the sideburn and one horizontal attached at the retroauricular or mastoid area.
Then comes the neck platysma, which has to undergo a platysmaplasty corset; first step is anchoring its lateral edge to the sternocleidomastoid muscle at the side of the neck; then and through a submental incision at the lower chin crease the medial edges or vertical bands are accessed and sutured to each other, creating thus the necessary tension to drape the neck up and delete the vertical bands; some other accessory maneuvers may be applied like myotomies or muscular cuts, myectomies or muscular resections, etc.
As mentioned before the last and not less important stage is the perfect skin adjustment under no tension to prevent bald patches, necrosis, pixie ears, tragus pull, lateral sweep and other deformities; it is not about holding up the face by simple tightening the skin but rejuvenating the deep structures of face and neck and then let the skin be extended and made fit smoothly.
This has been the international golden standard in face and neck rejuvenation during the last decades and Dr. Alejandro Nogueira's professional performance during his vast career; any other alternative has been and is failed, partial or troublesome.
Any intrinsic to the dermis aging signs or wrinkling need dermatologic treatment and not surgery, like fine photo aging, hyperdynamic creases or solar spots.