Aesth Plast Surg

DOI 10.1007/s00266-012-9995-x

ORIGINAL ARTICLE AESTHETIC

Anatomic Study of the Retaining Ligaments of the Face

and Applications for Facial Rejuvenation
Percy Rossell-Perry • Percy Paredes-Leandro

Received: 26 August 2011 / Accepted: 17 July 2012

Ó Springer Science+Business Media New York and International Society of Aesthetic Plastic Surgery 2012

Abstract other structures of the face are described here. This study
Background The retaining ligaments of the face support demonstrates that our face-lift technique is safe and pro-
the facial soft tissue in a normal anatomic position, thereby duces highly predictable and natural results.
resisting gravitational change. In this study, a technique Level of Evidence IV This journal requires that authors
utilizing surgical plication of the superficial musculoapo- assign a level of evidence to each article. For a full description
neurotic system (SMAS) to the retaining ligaments of the of these Evidence-Based Medicine ratings, please refer to the
face and finger-assisted malar elevation (FAME) dissection Table of Contents or the online Instructions to Authors www.
of the midface is presented. springer.com/00266.
Methods The anatomy of the facial retaining ligaments
was studied in 20 half-faces of ten fresh cadavers, and the Keywords Facial retaining ligaments
FAME

localization of the ligaments was examined macroscopi- Surgical face-lift
cally. Surgical correction of facial aging with plication of
the SMAS to the retaining ligaments and FAME dissection
of the midface has been performed in 74 face-lift patients Introduction
since 2006. Outcomes were determined by case notes,
clinical review, and a patient questionnaire. When the operating surgeon performs a face-lift, zones of
Results The studied ligaments (zygomatic and masse- adherence of the superficial musculoaponeurotic system
teric) were present in all cadaver dissections. The zygo- (SMAS) are encountered that alternate with zones where mobi-
matic ligament was located 4.3–5.5 cm from the tragus and lization proceeds with relative ease. These zones of adherence are
originates near the inferior border of the anterior zygomatic in relationship to the retaining ligaments of the face. Different
arch. The masseteric ligament was located 3.7–5.2 cm anatomic studies [1, 2] suggest that the cutaneous ligaments of
from the tragus below the junction of the zygomatic arch the face are in distinct anatomical areas; however, since the first
and masseter muscle. All the patients answered a satis- description by McGregor [3], there are some differences related
faction questionnaire and reported high levels of satisfac- to their location and additional studies are necessary.
tion at least 1 year after treatment. Facial aging is characterized by loss of balance of the facial
Conclusions We have identified the facial retaining lig- tissues due to gravitational forces. The retaining ligaments of
aments in all cadaver dissections and their relationship with the face support facial soft tissue in the normal anatomic
position, resisting this gravitational change. As this ligamen-
tous system attenuates, facial fat descends into the plane
Presented at the 19th Congress of the International Society of between the superficial and deep facial fascia, and the stigmata
Aesthetic Plastic Surgery, Melbourne, Australia, 2008. of facial aging develop. These soft tissue changes include
brow ptosis, acquired blepharoptosis, dermatochalasis, lower-
P. Rossell-Perry (&)
P. Paredes-Leandro
lid ectropion, midfacial ptosis, and jowl formation.
Jockey Salud Medical Center, Schell Street No. 1503,
Miraflores, Lima 18, Peru Since the description of the SMAS by Mitz and Peyronie
e-mail: [email protected] in 1976 [4], face-lift techniques involving this structure to

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rejuvenate the aging face have become reliable procedures Incision

for facial rejuvenation. Conventional SMAS treatment is
effective for minimizing the jowls and highlighting the The preauricular incision starts below the sideburn and
mandibular angle [5, 6]. However, this procedure has been continues with a tragal incision and in front of the earlobe,
criticized because it does not properly lift the malar fat pad as seen in Fig. 1. The incision is carried around the ear
and flatten the nasolabial fold (NLF) [7–9]. The disharmony lobule and ends directly behind the ear at the natural
produced by SMAS techniques alone, without addressing the anatomical depression between the mastoid process and the
midface, has gained attention since the 1990s. Aston [10] external ear canal. The length of the retroauricular incision
described a procedure called ‘‘finger-assisted malar eleva- depends on the severity of the facial aging, as seen in
tion’’ (FAME) which addresses the midface. This technique Fig. 1.
describes detaching the malar fat pad from the underlying
SMAS so it can be repositioned. This method has been used
in combination with SMAS techniques before. Graf et al. Neck Dissection
[11] uses a combination of the lateral SMASectomy tech-
nique described by Baker [12] to improve the lower third of The cervical region is treated with closed liposuction,
the face and the FAME method for midface dissection. Our medial platysma plication, and lipectomy of the submus-
technique is a combination of SMAS plication to the facial cular fat as needed. Additional closed liposuction to the
retaining ligaments plus FAME dissection of the midface. lower third of the face is performed in some cases.

Patients and Methods Facial Undermining

Cadaver Study The skin flap is elevated at the subcutaneous level leaving
some fat over the surface of the SMAS. The extent of this
This is a descriptive study. The anatomy of the retaining dissection proceeds to within 1 cm of the lateral orbital
ligaments was studied in 20 half-faces of ten fresh cadav- rim, across the malar region and into the anterior cheek to a
ers, seven men and three women, aged between 46 and point 2 cm lateral to the oral commissure (Fig. 1).
80 years. We performed the cadaver study at the Depart-
ment of Anatomy of San Marcos University in Lima, Perú.
The ten fresh cadavers were dissected and observed
macroscopically. The localization, extent, and relationships
of the ligaments were investigated. The zygomatic and
masseteric ligaments were dissected from their origins at
the facial bones to the level of their cutaneous insertion.
Relationships and distances from the tragus to the posterior
border of these ligaments were determined.

Clinical Cases

This is a case series study with a post test. Between June 2006
and June 2010, a total of 74 women underwent surgery for
treatment of different degrees of facial aging. Patients
requiring short-scar rhytidoplasty, SMAS plication to retain-
ing ligaments, and FAME dissection of the midface were
included in this study. Outcomes were determined by case
notes, clinical review, and a questionnaire (patient question-
naire assessment) (Table 3). None of these patients received
additional facial cosmetic treatments after the face-lift. Fig. 1 The design of the skin incision, SMAS plication, and facial
undermining. Blue line a short-scar skin incision for mild cases, blue
Surgical Technique dotted line a retroauricular skin incision for severe cases, black dot
line skin undermining, red dots: A = zygomatic ligament, B = mas-
seteric ligament, C = platysma auricular ligament, black arrows
All surgeries were performed under local anesthesia and SMAS-malar fat pad vectors of plication, dotted area area of
sedation. dissection with FAME procedure

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FAME (Finger-assisted Malar Elevation)

After subcutaneous dissection of the skin, the orbicularis

oculi muscle is elevated to access an avascular plane
between this muscle and the periosteum, described as the
prezygomatic space by Mendelson et al. [13]. This under-
mining can be performed either with a finger or a dissector.
Anteriorly and inferiorly, the dissection proceeds in the
direction of the NLF in the subcutaneous plane, leaving the
malar fat pad and the SMAS above it (Fig. 2).

SMAS Plication

The SMAS is fixed by plicating it to the retaining ligaments

of the face. The location of the retaining ligaments is easy to
identify because of the strong attachment of the SMAS to Fig. 3 SMAS (platysma) plication to the platysma auricular ligament
the underlying structures (bone, muscles, and parotid gland
fascia). The first suture of 5-0 mononylon is placed between
the platysma and preauricular parotid cutaneous ligament,
as described by Furnas [1], and located in the inferior
auricular region using an oblique vector of displacement
(Fig. 3). This plication improves the neck contour. Then, a
second suture is located between the SMAS-platysma and
the masseteric ligament in a vertical vector of displacement
(Fig. 4). This plication improves the facial jowls. Finally, a
suture is placed between the anterior SMAS (attached to the
malar fat pad) and the zygomatic ligament over the malar
area (Fig. 5). This plication improves the NLF.

Skin Redraping

Traction is applied obliquely to the skin without tension

both in front of and behind the ear. The skin incisions are
Fig. 4 SMAS plication to the masseteric ligament
closed over a suction drain, which is removed the following
day.

Fig. 5 Midface plication (malar fat and anterior SMAS) to the

Fig. 2 FAME procedure for midface elevation zygomatic ligament

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Results zygomatic ligament is related to the transverse facial

artery, zygomatic branch of the facial nerve, and zygom-
Cadaver Study aticus major and minor muscles (Fig. 6). The masseteric
ligament is related to the zygomatic branch of the facial
The zygomatic and masseteric ligaments were present in all nerve, zygomaticus major muscle, and parotid duct (upper
cadaver dissections. Results from the anatomic study are border) as well as the facial vein and buccal fat pad
given in Table 1 (Figs. 6, 7, 8). The inferior border of the (anterior border) (Fig. 8).

Fig. 6 The zygomatic ligament (black arrow), a prezygomatic space,

b orbicularis retaining ligament, c orbicularis oris muscle, d malar fat Fig. 7 Retaining ligaments of the face: (left) orbicularis retaining
pad, e zygomatic major muscle, f buccal fat pad ligament, (center) zygomatic ligament, (right) masseteric ligament

Table 1 Summary of the

Cadaver Side Gender Distance X (cm) Distance Y (cm) Distance Z (cm) Distance W (cm)
cadaver dissection study
1 Right M 5.2 5.0 1.2 2.0
Left 5.0 5.2 1.1 2.1
2 Right M 5.4 5.1 1.2 2.2
Left 5.3 5.2 1.0 2.3
3 Right F 4.3 3.7 1.0 1.5
Left 4.5 4.0 1.0 1.7
4 Right M 5.0 5.0 0.9 1.9
Left 5.1 5.0 1.1 2.1
5 Right M 4.9 4.7 0.9 1.7
Left 5.0 4.8 1.2 1.7
6 Right F 4.5 4.2 0.8 1.7
Left 4.7 4.4 1.0 2.0
7 Right M 5.0 5.1 1.0 2.0
Distance X: Distance from the Left 5.0 4.9 1.1 2.2
tragus (posterior border) to the 8 Right M 5.2 4.9 1.6 2.3
zygomatic ligament (posterior Left 5.5 5.2 1.4 2.1
border)
9 Right F 4.6 4.6 1.0 1.9
Distance Y: Distance from the
Left 4.9 4.7 1.2 1.9
tragus (posterior border) to the
masseteric ligament (posterior 10 Right M 5.5 5.2 1.2 2.4
border) Left 5.4 5.2 1.3 2.3
Distance Z: Distance between Range 4.3 ± 5.5 3.7 ± 5.2 0.8 ± 1.6 1.5 ± 2.4
zygomatic and masseteric Average ± DS 5.0 ± 0.336 4.805 ± 0.421 1.11 ± 0.181 2 ± 0.242
ligament

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Clinical Cases patients, elevation of the midface, improvement of the

NLF, and neck contour were obtained. There were few
Between June 2006 and June 2010, a total of 74 women complications and unfavorable results (Table 4). Only
with different degrees of facial aging were operated on three patients required a return to the operating room for
using our modified face-lift technique with or without a evacuation of an expansive hematoma which was per-
simultaneous upper and/or lower blepharoplasty, brow lift, formed under local anesthesia.
and submental liposuction (Table 2; Figs. 9, 10, 11). Their
mean age was 63.59 years (range = 45–72 years) and the
follow-up period ranged from 12 to 50 months (aver- Discussion
age = 26.21 months). Results from the patient satisfaction
questionnaire are given in Table 3. High levels of satis- Since its description, the conventional SMAS [4] face-lift
faction were achieved with our face-lift technique. In all is one of the most commonly performed rhytidectomy
techniques [7–9]. The presumptive localization of the
retaining ligaments based on this anatomic study and others
[1–3, 14] led us to elevate the facial tissues using a SMAS
plication. Our anatomic study provided information about
the location of the zygomatic and masseteric ligaments
necessary for SMAS plication (Table 1; Figs. 6, 7, 8).

Table 2 Associated surgical procedures

Procedures n %

Brow lift 62 83.78

Lower blepharoplasty 37 50
Upper blepharoplasty 21 28.37
Medial platysma plication 18 24.32
Submental liposuction 18 24.32
Facial liposuction 15 20.27
Fig. 8 The masseteric ligament (black arrow), a zygomatic major Buccal fat pad resection 9 1.21
muscle, b facial vein, c masseter muscle

Fig. 9 A 72-year-old patient: preoperative and 1-year postoperative photos

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Table 3 Results of patient

Question Answer
satisfaction survey
n %

1. How satisfied are you with the surgery?

1. Disappointed 1 1.35
2. Unsatisfied 1 1.35
3. Modest 3 4.05
4. Satisfied 30 40.54
5. Very satisfied 39 52.70
2. What is your personal impression about the outcome of the surgery?
1. Bad 2 2.70
2. Modest 3 4.05
3. Good 20 27.02
4. Very good 24 32.43
5. Beyond expectations 25 33.78
3. Would you recommend this treatment to other patients?
1. Yes 70 94.59
2. Not sure 2 2.70
3. Not 2 2.70
4. Do you have any permanent undesirable side effect after this surgery (unfavorable result)?
1. Yes 15 20.27
2. No 59 79.72
5. Are the outcomes of this treatment still maintained at this time? (1 year postoperatively)
1. Yes 74 100
2. Not 0
6. Did you regard your appearance as ‘‘natural’’?
1. Yes 69 93.24
2. Somewhat 4 5.40
3. No 1 1.35
7. What is the degree of your improvement by area?
Midface
1. None 2. Minimal 3. Modest 4. Very good 5. Beyond expectations
0 1 (1.35 %) 6 (8.10 %) 42 (56.75 %) 25 (33.78 %)
Nasolabial folds
1. None 2. Minimal 3. Modest 4. Very good 5. Beyond expectations
0 2 (2.70 %) 11 (14.86 %) 46 (62.16 %) 46 (62.16 %)
Contour of jawline
1. None 2. Minimal 3. Modest 4. Very good 5. Beyond expectations
0 2 (2.70 %) 5 6.75 %) 41 (55.40 %) 26 (35.13 %)
Contour of the front of the neck
1. None 2. Minimal 3. Modest 4. Very good 5. Beyond expectations
0 2 (2.70 %) 4 (5.40 %) 48 (64.86 %) 20 (27.02 %)

The distance between the zygomatic and orbicularis oris studies did not point out this practical information [1–3,
ligaments (entrance of the prezygomatic space) allows 14].
fingertip dissection of this space (depending on the width The SMAS plication to the retaining ligaments of the
of the surgeon’s finger) (Table 1). It may be difficult to face is necessary for restoration of the normal anatomic
perform the FAME dissection if the ligaments are too close structures of the face. Avoiding sub-SMAS dissection and
together or the surgeon’s finger is too large. Surgical dis- using subcutaneous dissection and SMAS plication con-
section would be necessary in this situation. Previous stitutes a safer way to avoid facial nerve injury. This is not

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Table 4 Complications among 74 consecutive SMAS fixation to the Recently, fixation to the middle-cheek region (location of
facial retaining ligaments ? FAME facelift procedures the masseteric ligament) was proposed by Stuzin [9],
Complications n % Mendelson et al. [13], and Ozdemir et al. [14], with some
differences with respect to our technique. However, the
Prolonged loss of sensation 22 29.72
elevation of the midface is not properly achieved with these
Dimpling 15 20.27 methods alone. Hamra [16] observed the lack of significant
Minor hematomas 12 16.21 improvement of the midface and nasolabial fold (NLF)
Hypertrophic scar 7 9.45 with conventional methods. The disharmony produced by
Asymmetry 5 6.75 SMAS techniques alone, without addressing the midface,
Facial nerve weakness 5 6.75 has gained attention since the 1990s.
Expansive hematoma 3 4.05 Ramirez [17] described endoscopic subperiosteal mid-
Partial skin necrosis 2 2.7 face elevation to improve the NLF area. However, subpe-
Infection 1 1.35 riosteal undermining of the malar fat results in more
Permanent facial nerve palsy 0 0 prolonged swelling than the supraperiosteal technique
Others 8 10.81 does. More effective results were obtained by combining
repositioning of the malar fat with SMAS procedures.
a new concept. In 1960, Aufricht sutured the subcutaneous Owsley and Zweifler [18] described their technique of
layer to the parotidomasseteric fascia [15]. The deep-plane undermining and elevating the malar fat pad with plication
face-lift surgery described by Skoog [5] included the fix- of the SMAS. Little [19] elevates the midface using a malar
ation of the SMAS to the masseteric fascia and ligament. imbrication, and Aston [10] elevates the midface using a

Fig. 10 A 50-year-old patient: preoperative and 1-year postoperative photos

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Fig. 11 A 42-year-old patient: preoperative and 1-year postoperative photos

fingertip dissection that he calls FAME. This method of Despite these complications, only 15 patients reported any
midface elevation is utilized by us to improve the NLF and undesirable side effect after surgery (Table 3). Our tech-
blend the eyelid–cheek junction. Using this procedure we nique based on retaining ligament suspension is still
elevate the suborbicularis oculi fat (SOOF) and the malar evolving, and the refinements to this procedure continue to
fat pad for suspension using the retaining ligaments of the develop, with an effort to enhance postoperative contour
face. while minimizing undesirable results.
The SMAS plication to the retaining ligaments of the
face permits us to obtain an individualized design because
the location of these structures may vary depending on the Conclusions
skeletal morphology of the patient. Our rhytidoplasty
produces safe and reliable results with a low rate of com- We found the facial retaining ligaments in all 20 cadaver
plications and limited incisions even for severe cases dissections and their relationship to the other structures of
(Figs. 1, 9, 10, 11; Tables 3, 4). the face is described here. This study demonstrates that our
Friel et al. [20] published a study on face-lift patient face-lift technique based on SMAS fixation to the facial
satisfaction. We created our own method of evaluation retaining ligaments plus the FAME technique is safe and
based on this publication. Our results are consistent with produces highly predictable and natural results.
previously reported studies regarding patient satisfaction.
Acknowledgments We thank Dr. William Schneider for his help
The most common undesirable effect was the prolonged with the English for the manuscript.
loss of sensation over the malar area, which was observed
by 22 (29.72 %) patients. This is probably related to injury Conflict of interest The authors have no conflicts of interest or
of the zygomatic branch of the infraorbital nerve which is financial ties to disclose.
located at the entrance of the prezygomatic space. This
space is dissected during the FAME procedure. Studies are
lacking regarding skin sensation after surgical lifting and it References
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