The Intraoperative Internal Measurements during the Deep Pre-Masseteric Subcutaneous Face Lift with Long Suture Loops and Vertical Plication Indicate a Favorable Spatial Repositioning of the Tissues.

Goals/Purpose: Aging results in tissue laxity more pronounced in the areas of movement, where there are fewer ligaments, such as in the anterior face. Stretching the mobile SMAS in the premasseter space with directional loop sutures, fixed in the parotid area, can be effective and less risky compared with the deep prolonged SMAS dissection. We designed a procedure based on two long loops suture and a vertical plication of the SMAS and measured the movement and stretching of the SMAS and the skin in the deep subcutaneous face lift

Methods/Technique: In total, 30 measurements were taken from 15 female patients (age 49–68 years). Five points were marked with the skin in supine position: mandibular (M)—1 cm superior to the mandibula edge into a vertical line reaching the palpebral lateral commissure; masseter (MASS)—in the border of the masseter muscle corresponding to the masseteric ligament; zygomatic (Z)—inferior border of the zygoma corresponding to the zigomatic ligament; helix (HE)—the superior helix insertion; intertragus (IT)—the intertragus notch. After the flap dissection, the points M, MASS, and Z were trespassed with a needle trhough the skin and marked in the SMAS. After subcutaneous dissection crossing the massetric and zygomatic ligaments, two loops are designed in this technique: 1.5 cm wide: one loop (L1) in the direction based from HE point to the M point, and 2 cm anterior to the preauricular incision, the second loop (L2) from the HE to the Z. Measurements were done: HE to M, HE to MASS, HE to Z, IT to MASS after loop 1, after loop 2, and after a final vertical plication designed from the mandibular border 1.5 cm from the lobule going superiorly to the zygomatic arc, 1.5 cm from the preauricular incision, 1.5–2 cm wide. Measurements were taken in the marked points in the skin: HE-M, HE-MASS, HE-Z, and IT-MASS before surgery and after skin resection (without tension). The results were compared in percentages.

Results/Complications: The measurements show a higher stretching of the SMAS in the distal zone, at the premasseteric area compared with the parotid area. The movements of the marked points show an oblique ascendent movement of the SMAS (around 45 degrees), whereas the skin marked points show a horizontal final movement. Even though the skin is only positioned avoiding much stretching, the amount of removed skin in the marked area was important (−36.98 at the IT-MASS line), equivalent to the stretching of the SMAS.

Conclusion: The use of log loops connecting the distal mobile spaces to the fixed masseteric SMAS area may be effective to treat the perioral aging alterations avoiding the risky sub-SMAS dissection. The loops may be designed according to the located laxity, wider or longer. The vertical plication adjusts the loops and are important to a horizontal SMAS dislocation. The redundant curled masseteric SMAS included into the loops and plication forms a bulky tissue that enhances de external face contour at this area, avoiding the stigmata of face lift based only on stretching the skin or SMAS.