Strategy for a Successful Facelift Following Six Vectors of Traction and Five Planes of Dissection: Our 10 Years of Experience

Goals/Purpose: A harmonious facial appearance is determined by a balanced correlation among the tissues of the face. Due to the aging process, balance is lost among the bone, muscle, fat and skin of the face, as progressive changes occur in their volume, shape, position, and consistency. Facial aging should be evaluated as a global process instead of a segmented one. Aging occurs in every structure of the face in different ways, depending on the vector of descent, thereby treatment must be individualized. Thus, one dissection plane cannot be applied to all parts of the face and also the traction vectors need be different in order to achieve good harmonious results. We propose a strategy for planning a successful facelift based on the individual needs of each patient by describing six individual traction vectors following dissection of the face in five different planes.

Methods/Technique: The superior third of the face is tractionned following two vectors:
The first vector (V1) elevates the medial forehead structures in a vertical direction after undermining in a subperiosteal plane with the aid of the endoscope to avoid injury to the neurovascular structures, and shifting to a supra periosteal plane at the level of the glabella in order to treat the procerus, corrugator and depressor supercilii muscles, if needed. Three fixation points are placed in the scalp in order to reposition the frontal region.
The second vector (V2) elevates the lateral brow and lateral orbital region in a superior oblique direction after undermining in an interfacial plane up to the superior temporal line. Then dissection is done in a supra-periosteal plane under endoscopic vision reaching the sentinel vein which defines the inferior border of dissection of the frontal and temporal areas. Traction of the superior temporal region is achieved by fixing the superficial temporal fascia to the deep temporal fascia with non absorbable 2-0 sutures.
The middle third of the face is tractioned also following two vectors:
The third vector (V3) elevates the anterior medial third of the face, in a superior oblique direction after undermining of the malar region in a supra periosteal plane (sub SMAS plane) and endoscopically repositionning the malar fat pad using three 3C triple convergence polypropylene sutures and fixing them up to the deep temporal fascia. By doing so, we can smooth the nasolabial sulcus and correct the malar fat pad descent.
The fourth vector (V4) elevates the antero-lateral third of the face also in a vertical direction following dissection of the tissues in a subcutaneous plane. A stair-like SMAS plication is performed in order to distribute the traction forces in a vertical direction.
The inferior third of the face and the cervical region are also tractionned following a fifth vector (V5) in an oblique direction, after undermining in a subcutaneous plane the lateral cervical and post-auricular regions, fixing the SMAS-platysma to the periosteum of the mastoid bone with nonabsorbable 2.0 sutures. This traction delineates the mandibular contour and accentuates the cervico-mandibular angle.
In cases of apparent medial platysma bands, traction of the cervical region is done following a sixth vector (V6) through a sub mental incision realizing a triple suture joining the medial borders of the platysma and the anterior belly of the digastric muscles, in a vertical direction, which delineates the cervical mental angle.

Results/Complications: We have planned 798 facelifts following these strategies from July 2000 to July 2010. By identifying the problem area of each patient and classifying them according to our six- vector strategy in the first consultation, we have been able to easily respond and fulfill their needs following these basic principles.
By performing a multi-plane face dissection, the soft tissues of the superior, middle, inferior thirds of the face and the cervical region can be lifted in order to reestablish their youthful relationship with the underlying skeleton. The subperiosteal approach alone, although easy and safe, is limited to younger patients in whom laxity of the soft tissue is not so pronounced. The composite rhytidectomy although repositioning and improving the deep tissues’ ptosis, creates a single composite flap that can be distorted by the multidirectional vectors.

Conclusion: Our approach is based on a systematic process where vectors 1, 2, 3 are addressed endoscopically and vectors 4, 5 and 6 by blinded dissection. Following this strategy, patients are treated according to their needs through short-limited or classic-extended incisions following a multi-plane dissection and the different traction vectors described above. This strategy has proven to be reproducible and reliable especially for young plastic surgeons in training and those in the beginning of their career, providing great and sustainable results in their patients.