The Hybrid Facelift.

In facelift surgery, many surgeons tend to choose one superficial musculoaponeurotic system (SMAS) technique over another. SMAS plication augments tissue using folding, which is very useful in deflated faces. In heavy faces, SMAS-ectomy and, to an arguably further extent, full SMAS undermining and excision can reduce volume and avoid the excessive fullness that may follow plication. Not all patients present with uniform deflation or uniform fullness of the face. Some will present with a mixed picture, fullness in one area such as the cheek with deflation in another (eg, over the angle of the mandible). In those patients, plication alone may lead to undesired fullness, typically overaugmenting cheeks or angle of the mandible. SMAS elevation and excision may avoid overaugmentation (arguably better than simple SMAS-ectomy), but it is technically more demanding and consumes longer operative time. An alternative approach is suggested in this article. For those patients with "mixed" pictures, we suggest a hybrid of existing SMAS techniques, in which for each side of the face, the face is divided into upper (cheek) and lower (jawline and neck) areas. Deflated areas are addressed with plication. Full areas are addressed with SMAS undermining and excision. Although this kind of surgical approach might be practiced by some surgeons, it has not been described well in the literature. In a series of 495 facelifts, the author found this "hybrid facelift" technique useful in 61 cases.