Introduction

The demand for anti-aging procedures increases year after year. This is influenced not only by a change in trends, the promotion of a healthy lifestyle, the influence of the media, or a change in attitude toward plastic surgery, but also a competitive environment in business and social life. The fact that a younger-looking person has more opportunities and perspectives is undeniable.

More than a century of experience in the use of anti-aging face surgeries has not led surgeons to the choice of a single optimal and unified method of operation. A confirmation of this fact is the continuing search for new techniques and methods for optimizing results. On the one hand, we can see this with the emergence of new technologies and the introduction of more radical interventions on the soft face tissues, and on the other hand, the obvious return of surgeons to more conservative and safe techniques [1, 2].

At the same time, the conceptual view of the anatomical structures of the face, the description of the retaining ligaments of the face, sliding spaces, facial tissues, and skeleton aging have changed over the last period of time [3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21].

Today, the requirements for efficiency and stability of the result with faster recovery, as well as for a less traumatic impact on the tissue, are increased by using short scar technique.

Analyzing and taking into account these trends, we have conceptually developed and put into practice the SMAS SUPPORT SYSTEM LIFT (triple-S lift) technique of face-lifting.

Materials and Methods

The technique is based on the following principles:

  1. 1.

    A short scar technique;

  2. 2.

    Safety SMAS (limited sub-SMAS dissection up to anterior border of masseter muscle);

  3. 3.

    The support system (a complex of ligatures in the sub-SMAS layer, which allows lifting and plication of the medial part of the SMAS simultaneously).

The operation has been performed on 93 patients of Slavic appearance from the end of 2016 to 2018. Among them were 85 women (91%) and 8 men (9%) with the age range from 38 to 72 years. The average age was 49 years.

The main goal of our research was to develop a minimally invasive effective face-lift surgery with the use of the short scar technique. Requirements for the method are to minimize the risks of damage to the nerves and salivary duct, reduce the number of complications, shorten the recovery period, and achieve long-lasting results.

Surgical Technique

Preoperative marking includes determining the type and length of incision. Depending on the preference of the patient, the pretragal or retrotragal approach is chosen. In the case of 1–2 types of ptosis (according to Baker DC), the incision goes from the earlobe to the temporal area, and then it makes the arch in the temporal region at the hairline or goes vertically to the scalp 1.5–2 cm above the helical rim [22]. In severe ptosis of cervical and jowl soft tissues, the incision line is also marked in the postauricular region, upwards to the posterior auricular muscle and 2–2.5 cm to the hairy part of the head (Fig. 1a). The following areas are marked: skin undermining zone (3.5–4 cm anteriorly from the ear), anterior edge of m. masseter, lateral margin of m. orbicularis oculi and malar eminence, and platysmal bands (Fig. 1b). The location of the lines of the ligature support system corresponding to the vector of lifting SMAS and soft tissues is also marked.

Fig. 1
figure 1

a Skin dissection options: for 1–2 ptosis type (green), for 3–4 ptosis type (yellow); b skin flap elevation marking (a dotted yellow line) and the SMAS (a red dotted line). A continuous red line marks the SMAS incision

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The operation is performed under general anesthesia with the use of Sevorane gas, which keeps hypotension at the level of 80–90/50–60 mmHg. for the optimal work of the surgeon. A limited use of muscle relaxant agents is recommended for better control of mimic muscle movements when the monopolar electrode reaches the motor nerve branches.

Aseptic preparation of the surgical area should be done with Octenisept solution or 0.5% chlorhexidine (CHX) aqua solution. This procedure begins with the infiltration of buffered local anesthesia utilizing both 1% lidocaine and epinephrine. After the skin incision, the subcutaneous tissue is tunneled with a 3-mm blunt liposuction cannula, and then the remaining vertical bands are transected with the scissors. This method of detachment is the safest and creates a smooth SMAS surface. The skin flap is separated medially on the cheek and neck for 3–5 cm. Creating a SMAS flap begins with a horizontal incision along the zygomatic arch with the Colorado electrode, 1 cm from the tragus, 3.5–4 cm long. Then, the incision is extended vertically up and stops at the edge of the orbicular oculi muscle. The preauricular vertical incision of the SMAS is performed 1 cm medial to the skin incision and is directed from the zygomatic arch down to the angle of the mandible. Then, the incision follows along the platysmal fibers 3 cm lower.

The corner of the SMAS flap is elevated with forceps, and the dissection proceeds anteriorly in the sub-SMAS layer with the monopolar coagulator while applying traction.

In the middle portion, the flap is mobilized to the anterior edge of the masseter and into the lower “sliding” space (according to Bryan Mendelson). The upper sliding space (prezygomatic) and McGregor’s ligaments are mobilized with a blunt tip cannula or closed scissors in the supraperiosteal layer. After the SMAS flap is completed, the support system is applied to provide the main lifting effect (Fig. 2).

Fig. 2
figure 2

Principle of ligature underrun through the SMAS and its anchoring to the platysma-auricular ligament for SMAS plicating

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The support system is placed in two planes: in the subcutaneous and sub-SMAS layers. It allows for performing medial SMAS plication and fixing the soft tissues to the anchor points on the temporal fascia, platysma-auricular ligament, and the fascia m. sternocleidomastoideus.

The support system is created with five hanging nonabsorbable braided sutures Ethibond 2-0 (Ethicon). The first suture goes through the mobile SMAS portion in the area of the malar fat and is sutured to the anterior edge of the temporal fascia.

The second, third, and fourth sutures are placed in three-ray direction.

These sutures are anchored in the area of the mobile SMAS portion 1.5–2 cm back to the nasolabial fold and then fixed to platysma-auricular ligament.

The fifth thread is anchored to the platysma 0.5–1 cm distal of the subcutaneous dissection, and then it is fixed to the fascia of m. sternocleidomastoideus.

The principle of passing the sutures

The thread penetrates the anchoring zone. Then, it goes through the sub-SMAS layer in the direction of the dissection end and comes out through the SMAS into the subcutaneous layer, and then it goes medially to the subcutaneous dissection end and again through the SMAS in the area of the transitional fold. After that, the thread goes back by the same route to the starting anchoring point. After knotting threads, the SMAS is elevated in the upper lateral direction with simultaneous plication of its medial part. The tension is transferred from the SMAS to the fixed anchor points [23]. The distal SMAS flap edge becomes tensionless. Then, the SMAS is divided into two flaps in the projection of the lower mandibular arch [13, 24]. The superior medial flap is replaced vertically upward and is fixed with interrupted stitches to the deep temporal fascia, covering the first–fourth sutures of the support system. The inferior lateral flap is moved to the retroauricular region in the form of a strap and fixed to the periosteum of the mastoid process without tension, covering the fifth suture (Fig. 3).

Fig. 3
figure 3

a Ligatures and the SMAS tension vector layout; b the SMAS displacement after the threads tightening. The distal edge of the SMAS is marked by a continuous red line

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The described suture system significantly reduces the tension on the distal flap and improves the stability of the SMAS fixation. Lifting degree does not depend on the thickness and strength of the distal flap portion and even the quality of SMAS edge fixation when the support system is applied. Furthermore, SMAS tissue redistribution in the distal portion can be used for volumetric correction of the temporal and supra-zygomatic region.

The skin is redistributed without tension in the upper lateral direction. Excessive skin is removed in the retroauricular and temporal regions with lateral rotation of excessive tissues and minimal tension outwards from the auricle.

The use of arcuate incisions reduces the dog-ear formation in the distal section of the incision and shortens the incision by almost two times compared to the classical approach, which uses linear incisions located along the hairline in the occipital region that are visible as a kind of sign (surgery’s signs) of the operation, especially when assembling a ponytail hair. When using rotary flaps in the future, there remains a short and inconspicuous scar in the hair that does not require special masking [25].

After the operation, active 2–3 mm drainages are inserted which are removed on the second–fourth day. An aseptic compressive bandage is used for 7–10 days. The stitches in the hairy part of the head are taken out at the 10–14th day. Absorbable Monocryl 4-0 intracutaneous suture is commonly used in the preauricular area.

Results

There were 93 procedures performed by using the triple-S lift technique during the period from the end of 2016 to 2018. The level of satisfaction with the achieved results reached 90% (Figs. 4, 5, 6). Neither necrosis nor nerve damage was registered. In one case, the female patient with previous long-term intake of anticoagulants experienced retroauricular hematoma, which was successfully drained with uneventful recovery and no wound revision was required.

Fig. 4
figure 4

A 36-year-old female who underwent SMAS support system lift. She also had liposuction of submental area. Preoperative views (above); 6 weeks postoperative (below)

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Fig. 5
figure 5

A 57-year-old female who underwent SMAS support system lift. She also had upper and lower blepharoplasty, liposuction of submental area. Preoperative views (above); 14 weeks postoperative (below)

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Fig. 6
figure 6

A 49-year-old female who underwent SMAS support system lift. She also had upper and lower blepharoplasty, liposuction of submental area and cheeks, submental plasty. Preoperative views (above); 2 years postoperative (below)

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Discussion

Anti-aging facial surgery is a little over 100 years old, originating from techniques that involve only the excision of excess skin folds. Gradually, it has become a more profound and delicate intervention. Since the description of the superficial muscular aponeurotic system (SMAS), new techniques have appeared including SMAS plication and resection [6, 22, 26]. More detailed study of facial ligaments, influence of mimic musculature, study of age-related changes in soft tissues of the face, and description of “sliding” spaces—all these factors had a great impact on the general tendency in the development of face surgery [8, 14].

From all the available literature about face-lift and interaction with the SMAS flap, we see that the predominant techniques are those, in which the surgeon either mobilizes the SMAS flap and fixes its distal part in different directions, or performs various types of intact SMAS plication with purse-string sutures.

An impactful trend has been noted in facial surgery lately. If at the beginning of the 1990s there was a significant enthusiasm of surgeons for endoscopic techniques and deep plane surgery and a noticeable decrease in the number of surgeries using SMAS plication, then since 2000 there have been more and more publications about returning to less traumatic techniques, shot scar incisions, and more limited sub-SMAS lifting [18, 27,28,29,30]. A striking example is the appearance of articles of a comparative nature between the efficiency of SMAS plication and deep sub-SMAS lifting [15, 17, 31, 32]. The frequency of complications and the duration of the achieved result are compared [33,34,35].

Special mention should be made of research that demonstrates that sub-SMAS face-lift complication rates were not statistically different compared to those of subcutaneous face-lift with or without SMAS plication. These data suggest that sub-SMAS dissection can be performed with similar safety compared to the traditional subcutaneous face-lift, with the potential additional advantage of the SMAS flap elevation [36].

Increasing demand among patients and surgeons for less traumatic and minimally invasive operative techniques is an undeniable fact nowadays. Hence, the emergence of short scar lift and MACS lift techniques with their intensive usage has become a vivid example of those processes. The authors of those methods suggest avoiding sub-SMAS dissection and suspending the non-undermined SMAS with purse-string sutures [19, 37, 38]. The description of the anterior SMAS lifting procedure has been presented as well, suggesting the beginning of SMAS flap formation in the medial portion of the SMAS, on the borderline between the fixed and mobile portions [16, 39,40,41,42].

The articles describing the elements of SMAS plication and lateral SMASectomy with simultaneous suture suspension of the malar fat are of great interest. The suture passes from the subcutaneous position where it is fixed to the malar fat pad, through the SMAS, and over the periosteum of the zygoma, and is fixed to the deep temporal fascia. Plication of the SMAS over the suture, combined with lateral SMASectomy, provides three vectors of elevation beneath the skin in midface rhytidectomy [43].

Each of those methods has its pros and cons. Because of this, we decided to invent a new method of face-lifting that combines the advantages of SMAS plication and the sub-SMAS lift. To achieve a stable soft tissue lift effect, we introduced the support system of nonabsorbable sutures [20].

The originality of our idea is based on the simultaneous detachment of the SMAS flap and the achievement of its lifting by a series of nonabsorbable ligatures (support system) in the sub-SMAS layer. The support system provides lifting of the medial portion of the SMAS flap and its plication simultaneously, while to some extent it simulates and compensates for age-related changes in the face retaining ligaments. This technique allows us to treat more medial SMAS portions with a smaller area of detachment. Dissection of the SMAS flap is usually limited to the anterior border of the m. masseter, unlike the many techniques of deep sub-SMAS face-lift. In this case, the support system reduces the impact on the distal part of the SMAS flap, which is fixed without tension and can be used to fill the volume in the temporal region. Sub-SMAS localization of ligatures reduces their exposure to the touch (tactile sensation) and allows for closing the “dead space” effectively. On the other hand, in contrast to the techniques of applying purse-string sutures and SMAS plications (MACS lift and S lift), our technique also has a more pronounced effect of lifting the medial portion of the SMAS, since the SMAS flap has greater mobility after detachment.

Such an approach minimizes the number of complications and achieves the desired vector of SMAS lifting. Merging all created spaces (subcutaneous and sub-SMAS) excludes the development of seromas and hematomas. Using this method allows for decreased tension from the created SMAS flap, so the lifting effect has minimal dependence on SMAS thickness and strength. All those aspects make it possible to use a short scar technique and reduce rehabilitation time.

For correction of aging changes of 1–2 type according to Baker (more precisely, the absence of objective and subjective changes in the neck), we use a short preauricular approach. The lower ligature in the neck is not used, the SMAS is redistributed upwards, and the retroauricular SMAS flap remains unengaged.

When correcting aging changes of 3–4 type, the lower ligature of the support system is aimed at improving the neck contouring and provides lifting of the platysma in the upper lateral direction due to lifting of the previously mobilized SMAS flap and forming platysma plication in the upper part of the neck. Applying the support system allowed for a vivid lifting effect at the neck and malar area.

Conclusion

The triple-S lift technique provides both lifting of the medial portion of the SMAS flap and its plication simultaneously. The special support ligatures in the sub-SMAS layer allow us to lift the medial SMAS portions with a smaller area of detachment and to fix the lateral part of the SMAS flap without tension.

Through minimal skin access, we have good result stability, safety, and shortened recovery time. Using limited detachment minimizes the probability of nerve trauma.

This technique is a latter-day one. It requires further study, but the present results are encouraging. All this allows us to recommend this technique as an option in anti-aging facial surgery.