What Changes When the Retaining Ligaments Are Handled

A facelift is not a single operation

'Facelift surgery' is commonly thought of as a single operation, but in practice it is divided into several approaches.

The differences come down to two things: how far the skin is incised, and how the SMAS is handled.

In general, all of these are called a 'facelift.' Within that, the extent and depth of surgery differ.

The key is the SMAS, and the retaining ligaments

The difference lies in how far the SMAS is addressed.

The SMAS (superficial musculoaponeurotic system, the facial fascial layer) is the structure that supports the deeper tissues of the face. That is why this layer is addressed together, rather than pulling only the skin. One approach is to dissect the SMAS over a wide area (separating the tissue between its layers) and to cut and release the retaining ligaments (cord-like structures that hold tissue to the deeper layers). Releasing the retaining ligaments widens the range over which the SMAS can be pulled. Conversely, with a dissection technique that avoids the retaining ligaments, the degree of improvement in deep wrinkle areas such as the nasolabial folds may be lower.

In simple terms: The face has a layer that supports the skin. That layer is held in place at several points inside the face by cord-like structures. Releasing those cords allows the supporting layer to be moved further. There are also methods that leave the cords untouched, but then deep wrinkles may be improved less.

Our clinic's facelift is usually a deep plane technique, with thorough SMAS dissection. In cases with a higher risk of nerve injury, such as revision surgery, a different method may be used.

The facial nerve runs near the retaining ligaments

The difficulty of handling the retaining ligaments comes down to the nerves.

The facial nerve (the nerve that moves facial expressions) runs near the retaining ligaments. This is an area that must be handled carefully, with precise knowledge of the anatomy. Because there is risk involved, a surgical technique that avoids the retaining ligaments is sometimes chosen. Which to choose is decided based on the condition of the face and the surgical history.

In simple terms: A nerve that moves facial expressions runs right beside that cord. So when releasing the cord, the surgeon must know where the nerve lies and work carefully. To reduce risk, a method that leaves the cord untouched is sometimes chosen.

The side effects of a facelift and what we pay particular attention to after surgery are summarized in [Facelift surgery information](/lifting/facelift). What we look at in revision surgery is in [Revision facelift information](/lifting/revision).

Surgery takes longer

A technique that releases the retaining ligaments thoroughly involves a wider surgical area and more complex suturing, so it takes longer.

A facelift at our clinic takes 4–5 hours when performed alone. When combined with facial fat grafting, liposuction, and double chin muscle tightening, it takes roughly 5–6 hours.

Every time I perform this surgery, I clear my mind and proceed carefully and slowly.

No approach is established as better

We do not claim that the deep plane technique is better than other techniques.

When multiple studies are pooled, the complication rates of the deep plane technique and other SMAS techniques were at a similar level. Which one lasts longer has also not yet been settled.

The study summary and reference list are reproduced as they are under “Do complications differ between the deep plane and other techniques?” on [Facelift surgery information](/lifting/facelift).

The method is decided after an examination

The same surgical method cannot be applied to everyone.

Accurate diagnosis and consultation, and choosing a method suited to each individual, are important. What to do is decided during the examination.

Item	Guideline
Where approaches differ	Extent of incision and how the SMAS is handled
When the retaining ligaments are released	The range that can be pulled widens
When the retaining ligaments are avoided	The improvement of deep wrinkles may be lower
Why caution is needed	The facial nerve runs right beside them
Comparing the approaches	Not yet settled