The Mini-Lift

Richard Zoumalan MD, Anil R. Shah MD, John Westine MD*
NYU School of Medicine, Division of Facial Plastic Surgery, Department of Otolaryngology, New York, New York
NYU School of Medicine, Division of Facial Plastic Surgery, Department of Otolaryngology, New York, New York, Assistant Clinical Professor
University of Florida, Assistant Clinical Professor, Division of Facial Plastic Surgery, Department of Otolaryngology, Private Practice, Delray Beach, Florida
*Corresponding author

HISTORY

Mini-lifts have been used for almost a century, with the first description of a mini-lift by Passot in 1919. Originally, these operations involved minimal subcutaneous skin undermining and limited skin excision with subsequently minimal improvement and short-lived results. However, the mini-facelift, or mini-lift, has evolved to describe a variety of facelifts which utilize minimal incisions, decreasing the need for postauricular and scalp incisions. (Matarasso).

TYPES OF MINI-LIFTS

The authors distinguish mini-lifts from full facelifts by the length and type of incision.  Within the category of mini-lifts, there are a large variety present based on the type of incision, as well as the amount of dissection and type of lift.  Figures 1-5 demonstrate a variety of incision types including the U, J, S, and extended S shaped incision.
Once the skin is elevated, the type of lift can vary depending on the surgeon’s preference and the patient’s aesthetic needs.  Variations can include suture imbrication and plication techniques, SMAS flaps, and even more extended deep plane techniques.

CANDIDATE SELECTION

Appropriate use of the mini-lift is paramount in achieving commendable results.  Due to the fact that a mini-lift has a shorter scar, ideal candidates have limited skin laxity.  Large amounts of skin can be difficult to redrape with mini-lift approaches and require longer incisions.  Typically, candidates who are excellent candidates for a mini-lift are younger patients with limited skin laxity and patients requiring “tuckups”.

Baker developed a classification schema to help identify patients who are appropriate candidates for a minimal incision rhytidectomy techniques  (See Table).  Although his classification is based on his variant of minimal incision rhytidectomy with lateral SMASectomy, it is useful guideline for surgeons who utilize mini-lifts.

The “type I” patient, the ideal candidate for the procedure is a female in her early to late 40’s with aging primarily in the face. The patients have early jowls with or without submental and submandibular fat.  The “Type II,” good candidate is a patient in their late 40’s to early 50’s, with moderate jowls and moderate skin laxity. Patients have microgenia with submental and submandibular fat. These patients do not have medial platysmal bands.  The “Type III,” fair candidate is in their late 50’s to early 70’s with significant jowling, moderate cervical laxity, and definite existence of submental and submandibular fat. Midline platysmal banding exists on animation. The “Type IV,” poor candidate are in their 60’s to 70’s with significant jowls and active lax platysmal banding. They have severe cervical skin laxity and deep skin creases below the cricoid. These patients are not suitable for any time of minimal incision procedure. They need extensive dissection and re-draping of the platysma, which requires a larger incision.(Baker)

S-lift and S-Plus lift

In the late 1990’s, Saylan introduced the “S-lift,” a short scar, short-flap facelift technique. The S-lift combined the advantages of limited incision and dissection with the advantages of SMAS lifting and manipulation. Saylan described using purse-string sutures to suspend the mobile SMAS and the extended platysma flap to the mastoid periosteum and zygomatic arch fascia. Utilizing a skin flap 5 to 7 cm long, U and O sutures are used to plicate the SMAS and fixate to the zygoma. (Saylan) The S-lift is a SMAS multi-plane rhytidectomy. It combines aspects of Baker’s lateral SMASectomy and suspending the ptotic malar fat pad to the temporalis fascia described by Tonnard et al. (Baker, Tonnard) A variation of this lift may be made to extend the SMAS flap into the midface, termed an S-Plus lift.

The S-lift is ideal for patients with mild-to-moderate neck laxity and mild-to-moderate jowling without platysmal banding.  The S-Plus lift with midface extension is better suited for patients with moderate to severe midface laxity/ptosis and malar insufficiency. If patients have platysmal banding at rest, a platysmaplasty must be added to the S-lift or the S-Plus lift. (Hopping)

 Short Scar

The short-scar facelift described by Matarasso uses an incision that begins in the horizontal aspect of the sideburn, extends to the pre-auricular region, curves around the ear to the post-auricular notch, and ends in the post-auricular sulcus 2-3 cm from the lobule. There are no incisions in the temporal or mastoid areas. Once again, due to limited access to the platysma, midline submentalplasty is required in more patients than in traditional face-lift (76% vs. 10%). The procedure always begins with suction lipoplasty or the neck and jowls. The SMAS is addressed either with resection, plication, or anterior imbrication.  (Matarasso) SMAS plication versus imbrications or resection have all been shown to be equally effective. There have been no differences in facial nerve paralysis between the techniques. (Webster)  Even Stuzin et al. who advocate an extended SMAS dissection, recognize plication as a useful alternative to SMAS elevation. (Stutzin)

With the use of sprayed fibrin glue, the authors have demonstrated safety of this procedure without the use of suction drains. As with other  mini-lifts, the use of the short scar has the usual potential complications of bunching at the temporal and post-auricular regions, which often self-resolves.  It also has shortcomings in the access to the temporal region as well as lack of wide and inferior access to the neck.  The author reports a high degree of acceptance along with lack of hair-bearing incisions which cause alopecia and lack of unsightly mastoid scars. (Matarasso, Matarasso).

Minimal Access Cranial Suspension Lift  (MACS-lift)

Tonnard modified the incisions and suture placement of the S-lift and created a mini-lift designated as the Minimal Access Cranial Suspension Lift (MACS-lift).  The philosophy behind this lift is that patients in a younger age range (40s to 50s) require a more vertical lift compared to the posteriosuperior lift of most facelifts.  This type of lift would theoretically provide more fullness to the face rather than flatten it.  If necessary, submental liposuction is performed first.

In the simple MACS-lift, an inverted L-shaped incision is made from the inferior portion of the auricle along the pre-auricular crease, turning anteriorly along the inferior aspect of the sideburn. A subcutaneous skin flap is dissected to extend 5cm anterior to the incision, superiorly to 1cm above the zygomatic arch, and inferiorly to the angle of the mandible. A pretragal  purse-string suture is anchored in the deep temporalis fascia. The suture continues inferiorly in a narrow U-shape, incorporating the SMAS overlying the parotid gland and ending in the platysma at the angle of the mandible before returning to the starting point 1 cm anterior to the first leg of the suture. A second, more O-shaped, purse-string suture is then placed from the same starting point at around a 308 angle to the first suture, reaching the extent of the subcutaneous  dissection. This suture, once placed under tension, should elevate the jowls and marionette grooves. The skin is then elevated superiorly, and excess skin is excised. The skin is then closed without tension. The ear lobe is repositioned as a transposition flap to avoid the superior pull of the skin. (Tonnard)

ADVANTAGES OF THE MINILIFT

Limited Incisions

Although the incision is limited to the pre-auricular area, the mini-lift allows access to the midface, jaw-line, and neck. The limited incisions of the S-lift lead to limited scarring. If one wishes to perform malar fat pat suspension, the incision can be extended superiorly into the temporal scalp.  This extension can also be helpful with SMAS flap manipulation, whether it be SMASectomy or mattress suture placement. (Hopping) The limited incision also allows for a “ponytail-friendly lift” due to its lack of a lengthy post-auricular incision. There is no posterior hairline distortion, hypertrophic scars, and hypopigmentation seen in patients who have extended facelifts. (Baker) Younger patients are very particular about this and seek to have a surgery that will allow them more flexibility of how they can wear their hair for the rest of their lives.

Reduced Surgical Time

While aesthetic outcome should never be sacrificed for surgical time, decreased operative time leads to less operative and postoperative complications. Reduced operative time also requires less anesthesia, which decreases the inherent risk of the operation.  Addition time gained by performing mini-facelift can be used towards adjunct procedures such as submentalplasty, chin implantation, forehead rejuvenation, etc.  (Hopping)  Reduced surgical time and less anesthesia leads to decreased cost, which is important to some patients.

Potential of Sedation

The mini-facelift is better tolerated by patients who opt to have their operation performed without general anesthesia. The mini-facelift can be safely performed and is tolerated by patients under local anesthesia with or without sedation.  It can also be performed under MAC without endo-tracheal intubation or laryngeal mask airway (LMA). Overall, patients who undergo the procedure without general anesthesia have less postoperative nausea and vomiting. (Tanna) The patient must be chosen appropriately, as some patients tolerate awake procedures better than others.

Risk Minimization

The accessibility limits dissection into the area of the greater auricular nerve, which leads to less instances of damage to this commonly injured nerve. The limited access and dissection also avoids the rich vascular supply of the posterior-inferior neck, leading to less postoperative ecchymosis and hematoma. (Hopping) When hematomas do occur, evacuation is easier and has less morbidity (Baker).  In addition, as the dissection in the deep-plane is less extensive, risk of injury to the facial nerve is diminished.

Recovery

Patients who undergo mini-facelifts have shorter recovery periods. The limited area of dissection leads to less ecchymosis and edema.  These patients also have less pain. (Baker) The lack of posterior auricular incisions actually leads to less surface area for healing and less alopecia. (Hopping) Women in the workplace favor such operations. The decreased recovery time allows them to return to work earlier, and they are less likely to be discouraged due to societal pressures. (Brackup)

DISADVANTAGES OF THE MINI-FACELIFT

Limited access to the neck

The short incision and lack of post-auricular extension limits access to the neck for access to the anterior, inferior, and posterior neck. The sternocleidomastoid area is difficult to expose. These limitations can result is a less than dramatic change in the neck contour. This presents the greatest limitation to aged necks in older females. This is precisely why a mini-facelift is a better option for younger patient. On older patients, some surgeons will supplement the mini-facelift with a midline platysmaplasty to improve the outcome of the neck. This problem can also be abated by extending the pre-auricular incision behind the ear by 2-3 cm. This will allow for better access to the neck to potentiate the placement of a better suture vector pull.  (Hopping)

Limited access and improvement in the midface.

Similar to access to the inferior neck area, access to the superior malar fat pad is limited. In the case of a severely ptotic malar fat pad, patients may be better off with a superior extension of the incision into the temporal hair to allow access to the malar fat pat area. (Hopping)  Patients with prominent nasolabial folds may also benefit from traditional facelift. (Tanna)

Dog ear /excess tissue

The lateral pull of tissues and skin in patients with moderate to severe skin laxity can lead to dog-ear at the inferior aspect of the lobe. This occurs when the incision is limited to the pre-auricular area. If one encounters this, the incision must be extended post-auricularly by a centimeter. Patients can also have excess skin at the earlobe, which can be dealt with by extending the incision post-auricularly.  This short extension of the incision is barely noticeable and does not generate complaints. (Duminy) Excessive soft tissue bunching at the pre-tragal area can be seen in some patients postoperatively. This fullness is a result of cinching of the SMAS tissue from suture placement. (Baker) The fullness resolves in 2-3 months with gentle massage. (Duminy)  With a short incision, dog ears can also form at the superior extent of the incision. These do not flatten easily (Baker).

Difficulty in visualization

Especially when it comes to SMAS manipulation of neck work, the limited incision of a mini-lift inhibits visualization of the surgical area. This not only makes manipulation difficult, but also creates a challenge in anterior suture placement, as well as hemostasis.

CONCLUSION

The variety of mini-lift techniques gives the surgeons options.  Surgeons across the country use various techniques in face lift surgery.  In a 1999 survey of 570 surgeons,  when asked which level of face lift describes that which they generally perform, 15 percent of surgeons responded that they generally perform skin-only procedure, and 74 percent said they address the SMAS. Nine percent of surgeons prefer a composite or deep-plane lift. (Matarasso)  Since then, there has been much in the way of literature about mini-lifts.  With a younger population seeking facial rejuvenation who also seeks to return to work and social events as soon as possible, more patients will opt for mini-lifts in the future.  These patients will have the added benefit of being able to wear any hairstyle they wish. For the right candidate, a mini-lift can provide a quick, safe, and effective method for aesthetic improvement of the aging face.

BIBLIOGRAPHY

Hopping SB. Minimally Invasive Face-lifting: S-Lift and S-Plus Lift Rhytidectomies. Oral Maxillofac Surg Clin North Am. 2005 Feb;17(1):111-21.

Hunt, H. Plastic Surgery of the Head, Face and Neck. Philadelphia: Lea & Febiger, 1926.

Gonzales-Ulloa, M. Facial wrinkles: Integral elimination. Plast. Reconstr. Surg. 29: 658, 1962.

Skoog, T. Plastic Surgery: New Methods and Refinements. Philadelphia: Saunders, 1974.

Mitz, V., and Peyronie, M. The superficial musclo-aponeurotic system (SMAS) in the parotid and cheek area. Plast. Reconstr. Surg. 58: 80, 1976.

Hamra, S. T. The deep-plane rhytidectomy. Plast. Reconstr. Surg. 86: 53, 1990.

Passot R. La chirurgie esthetique des rides du visage. Presse Med1919;27:258-262.

Saylan, Z. The S-lift: Less is more. Aesthetic Surg J. 1999; 19:406.

Baker DC. Minimal incision rhytidectomy (Short scar facelift) with lateral SMASectomy; evolution and application. Aesthetic Surg J. 2001; 21;14.

Tonnard P, Verpaele A, Monstrey S, Van Landuyt K, Blondeel P, Hamdi M, Matton G.Minimal access cranial suspension lift: a modified S-lift. Plast Reconstr Surg. 2002 May;109(6):2074-86

Matarasso A, Rizk SS, Markowitz J. Short scar face-lift with the use of fibrin sealant. Dermatol Clin. 2005 Jul;23(3):495-504, vii. Review.

Matarasso A, Rizk SS. Use of fibrin sealant in short scar facelift. In: Saltz R, Toriumi DM, editors. Tissue glues in cosmetic surgery. St. Louis (MO)7  QualityMedical Publishing; 2004. p. 134– 47.

Tanna N, Lindsey WH. Review of 1,000 consecutive short-scar rhytidectomies. Dermatol Surg. 2008 Feb;34(2):196-202; discussion 202-3. Epub 2007 Dec 17.

Brackup AB. Advances and controversies in face lift surgery. Curr Opin Ophthalmol. 2003 Oct;14(5):253-9.

Matarasso A, Elkwood A, Rankin M, Elkowitz M. National plastic surgery survey: face lift techniques and complications.  Plast Reconstr Surg. 2000 Oct;106(5):1185-95; discussion 1196.

Duminy F, Hudson DA. The mini rhytidectomy. Aesthetic Plast Surg. 1997 Jul-Aug;21(4):280-4.
Webster RC, Smith RC, Papsidero MJ, Karolow WW, Smith KF: Comparison of SMAS plication with SMAS imbrication in face lifting. Laryngoscope 92:901, 1982

Stuzin JM, Baker TJ, Gordon HL, Baker TM: Extended SMAS dissection as an approach to midface rejuvenation. Clin Plast Surg 22:295, 1995

Table I.  Baker Classification for Minimal Incision Rhytidectomy.

Interpreted from:  Baker DC. Minimal incision rhytidectomy (Short scar facelift) with lateral SMASectomy; evolution and application. Aesthetic Surg J. 2001; 21;14.

Candidate Type	Age	Jowling	Cervical Skin Laxity	Submental, Submandibular Fat	Micro-genia	Platysmal Bands	Misc
I – Ideal	Early to late 40’s	Early signs	Slight	+/-	+/-	–	Good cervical skin elasticity
II – Good	Late 40’s to late 50’s	Moderate	Moderate	+	+/-	–
III – Fair	Late 50’s, 60’s, early 70’s.	Significant	Moderate	++	+/-	+ (on animation)	Some 2ary rhytidectomy
IV	Late 60’s and 70’s	Significant	Poor	+++	+/-	++	Deep cervical creases