Dr. Little’s Techniques
Surgical Techniques for the Face
The Three Surgical Planes of the Face
Over his career, Dr. Little has performed 100s of facelifts in each of the three surgical planes of the face: the subcutaneous (superficial) plane, the SMAS or submusculoaponeurotic (middle) plane, and the subperiosteal (deep) plane. While all have yielded good results, he now prefers to work in the superficial plane alone, where he feels he has the best control over facial shape and architecture (which he considers the most important goal in facelift), repositioning the excesses of the jowl back to the low cheek or submalar region. He also finds this plane the most effective for resuspending the slumped oral commissure or corner of the mouth (which he considers the most difficult goal in facelift). But he also continues to work in the deep plane in selected patients. He no longer works in the middle plane, however, with its close proximity to the vital structures of the face, such as the seventh cranial or facial nerve (although many accomplished facelift surgeons continue to prefer this plane). He thus performs four distinct facelifting procedures (all of his design), that he combines with each other or with fat grafting into eight different “rejuvenation techniques” for the face.
The Surgeon versus the Technique
While the selected technique is important to the success of any surgical outcome, some argue that the surgeon contributes more. But there are many facelift techniques in use today that are limited by their very design to less effective outcomes and compromised results, regardless of who might be operating. Of course, no facelift expert would embrace such a flawed or “short-cut” approach. And, yes, these same experts each place great reliance on their personal, favored techniques–no two of which, by the way, are entirely alike and many of which are strikingly different. When a panel of such experts each presents good facelift results with a wide range of differing approaches and techniques, however, the moderator may conclude that the skill of the surgeon is more important to the result than is the exact nature of the technique. Said another way: good surgeons get good results, whichever technique they use. But Dr. Little still sees a range of results within even the best of such panels. A superior technique–based on sound artistic and surgical principles–he finds, helps the good surgeon get even better results. [And, yes, Dr. Little is one of those experts who places great reliance on his personal techniques…as detailed throughout the web site.]
1. XJ lift
Dr. Little’s basic facelift, the XJ (external jowl) lift (also known as the “paramedian lift” to his professional colleagues), targets the key tissues of established facial aging: the jowl, lower face, jawline, and mouth. After the skin cover has been freed from the fatty layer through the hidden, short-scar Ω incision, the soft-tissue redundancy of the “jowl complex” is redistributed up to the lower cheek (submalar zone) by a fine, absorbable (4-0 pds) suture. [view: Components of the “Jowl Complex” in diagrammatic form] This surgical manipulation is limited to the most superficial layer in facelifting, the fatty tissue immediately beneath the skin…placing it among the least invasive facelift techniques in use today. While less invasive, however, it is of broader scope than most, as the degree of undermining (the creation of the pocket between the skin and fat) extends over the jowl, approaching the corner of the mouth. Such freeing of the skin from the outer aspects of the jowl allows the soft-tissue redundancy of fatty jowl and lower face to be repositioned–without tension–in a strictly vertical direction (up to the lower cheek), while the lax lower facial skin is repositioned in a different, vertical-oblique direction toward the sideburn. Such unfettered access also affords a range of local manipulations that favor a return of the fallen corner of the mouth back toward an earlier position.
Dr. Little has found that vertical suspension of the jowl to the lower cheek has been more effective in his hands than attempts to reposition the jowl through traditional manipulations in front of the ear that use oblique as opposed to vertical movements. Also, moving the redundant tissues to such a near-by location (the emptiness of the lower cheek is only an inch away) allows long-term correction without tension or heavy sutures. Although the delicate 4-0 pds suture engages only the fatty tissues of the jowl itself, when tied it resuspends not only the fallen jowl, but also the descended platysma muscle (the supportive SMAS layer or “undercarriage” of the neck) that is fused to the fat layer, as both slide freely upward over the glide plane of the premasseter space deep to them. This anatomic space allowing easy vertical movement of the jowl without tension is a recent finding in human facial anatomy (Mendelson, B.C., Freeman, M.E., Wu. W., and Huggins, R. Surgical anatomy of the lower face: the premasseter space, the jowl, and the labiomandibular fold. Aesth. Plast. Surg. 32: 185, 2008).
The wider skin undermining or pocket creation brings at least four other benefits to the operation: it allows direct further reduction of jowl fat by scissors sculpture in the patient with challenging, heavy jowls; it allows direct and straightforward weakening of the muscle that pulls the angle or corner of the mouth downward (depressor anguli oris), reversing the difficult “bitterness folds;” it allows simple, direct suspension of the muscle complex to the side of the mouth, known as the modious; and it allows wider redraping of the facial skin, with enhanced improvements to the facial skin complexion and the creases along the nose and mouth (nasolabial and labiomandibular or “marionette” lines). But while the freeing of the skin extends forward almost to the corner of the mouth, it need not extend down and across the neck (from “ear-to-ear”) in most patients. Following resuspension of the jowl (without tension), the skin is also resuspended and tailored without tension (Dr. Little’s “reversed gradient” skin suspension), using a single, fine, absorbable (5-0 vicryl) suture at the key suspension point. Such tension-free redraping is enabled through the use of tissue adhesive (Dr. Little prefers “autologous platelet gel” derived largely from the patient’s own blood). A component of this platelet gel, PRP or “platelet-rich plasma,” with its concentration of platelet-related growth factors, is also mixed with the fat cells for grafting and may enhance the “take” of the grafts. The XJ lift can be reviewed schematically. [view: Basic XJ Lift in diagrammatic form]
Dr. Little has included his XJ lift in nearly every full facial rejuvenation he has performed over the past two decades. It represents the superficial portion of his published combined facelift technique (see: about Dr. Little / abbr. C.V. Part II: publication #101). It is now performed alone in the vast majority of his patients, correcting the jowl and restoring the healthy “inverted-cone-of-youth” facial shape by simple redistribution of the excesses of the jowl back to the deficiencies of the lower cheek. There is no longer a need to work in deeper aspects of the face to correct the lower lid hollow, as this is more efficiently treated with the needle (microstructural fat grafting), bringing a significant savings in surgical time and recovery. And for the thinner patient with extra needs in the cheek area, this area is also addressed by the fat-grafting needle, in a matter of only a few extra minutes.
2. “Malar Imbrication” Midface lift
Dr. Little’s midface lift, published as the deep portion of his combined rejuvenation technique (see: about Dr. Little / abbr. C.V. Part II: publication #101), returns facial volume to the upper cheek and lower eyelid area without the need for skin incisions (the two short scars are located within the scalp and mouth). Imbrication means “stacking,” as the deeper tissues of the lower cheek are stacked higher beneath those of the upper cheek. Midfacial suspension is accomplished by a single absorbable suture (this time a heavier “2-0” vicryl) positioned through the mouth incision, again without tension. [view: Malar Imbrication Midface Lift in diagrammatic form] Impressive improvements typically follow to the cheek, lower eyelid region, and mouth. Performed alone, however, any midface lift brings only limited improvement to the jowl complex, jawline, and neck, where most established aging resides. Therefore this “scarless” internal facelift becomes appropriate only in selected patients with earlier aging and fewer concerns about the jowl and neck region. Or it may be added to the XJ lift as a “combined lift.” “Malar imbrication,” whether performed as part of a “combined” procedure or alone, requires only minimal operative time.
3. Cable miniLift
For patients with concerns about face and neck aging (or re-aging after prior surgery), but where jowl formation remains limited, this minilift offers a compromise between the minimalist composite micro lift and the standard XJ lift. Here the hidden short-scar incision around the ear is utilized (as in the XJ lift), but the subcutaneous undermining (pocket between the skin and underlying fat) is limited to only one-third to one-half the standard amount. A Labbé-style cable suture from below the earlobe to the back border of the platysma neck muscle (see: Dr. Little’s Techniques > Neck) becomes a necessary component of this lesser facelift to ensure worthwhile improvement to the neck, while the more forward aspects of the face are left undisturbed. [view: Cable miniLift in diagrammatic form] While this mini lift requires little more than half the operative time of the XJ lift, it can bring impressive rejuvenation to the appropriate patient.
4. XJ Lift with Malar Fat Graft
Although not strictly a separate operative technique, Dr. Little thinks of this combination as a distinct architectural variation of his basic facelift, whereby the profile of the upper cheek is further enhanced in a subtle to moderate way by adding conventional structural fat grafts to the upper face and cheek. This ten-minute enhancement to the basic XJ lift is performed in Dr. Little’s thinner patients or in those who have always envied fuller cheeks. Thinner persons in general develop facial aging both earlier and to a more visible degree than their fuller-faced friends, who have facial fat reserves in place from which to lose some volume before the hollowness of age sets in. Again, there is never any pressure to “push” the original enhancement, as the cheek area can be readily “boosted” further in the office, after the facelift recovery is complete and the final facial balance exactly apparent. Thus can the patient be kept “in control” throughout the rejuvenation decision-making process.
5. Combined Lift
The malar imbrication midface lift may be combined with the basic XJ lift to emphasize enhancements to the upper face and cheek areas, while also correcting the key lower facial redundancy. Technically, this combination joins two independent lifting maneuvers, one in the most superficial plane of the face (the XJ component), the other in the deepest or subperiosteal plane (the mid facelift). Dr. Little often utilized this combination in the past, before he developed his form of micro structural fat grafting to correct the deficiencies of the lower-lid area and tear trough. Now he prefers the needle (fat grafting) for tear-trough correction and cheek enhancement in most patients. But the “combined” approach remains a powerful option in cases of particular need (the patient who appears much older than her chronological age) or particular aspiration (the patient who wishes the most impact possible from a rejuvenation point-of-view). While the added deep-plane surgery adds only 30 minutes to the total operative time, such surgery in two planes prolongs overall recovery.
6. Composite micro Lift
This minimalist facelift requires only a short scar underneath the sideburn, down to the top of the tragus (the bump in front of the ear), with a second half-inch scar above it in the temple scalp. A permanent suture secures the thicker tissues of the upper cheek region to the bony area in front of the ear. It is usually performed in the office under local anesthesia, requiring only minimal operating time, with full recovery in a few days. If all this sounds a little bit “too-good-to-be-true”, it is…at least for the first-time patient with established aging of the jowl and neck. Such a limited intervention cannot bring sweeping, lasting improvement to fully-developed facial aging. But it may be just the right minimal intervention in certain patients. And it is a powerful “booster” of prior surgery, where the jowl has been properly suspended but is now beginning to show itself again.
7. Composite micro Lift with Fat Graft
Many times the composite micro lift is combined with structural fat graft to the lids, lips, cheeks, or other areas of the face to further enhance its impact, while maintaining its minimalist nature.
8. Fat Graft (Alone)
Dr. Little was among the early advocates of smaller instrument size in fat graft and in 2001 reported the discovery of an existing, delicate, blunt ophthalmic needle ideally suited for fat graft in the challenging areas of the eyelids and lips (see: about Dr. Little / abbr. C.V. Part II: publication #112). Such “micro” structural fat graft led the way for the extensive simplification he has been able to bring to his overall facelift procedure. Such fat graft (to which he adds the patient’s PRP or platelet-rich plasma with concentrated growth factors) is now an integral part of virtually all of his facelifts. [view: Structural Fat Graft during XJ Lift in diagrammatic form] But fat grafting alone, without surgery, has also become a straightforward option for many patients, especially those who have developed hollow faces and eyes earlier than expected in life. Here fat may be added to not only the more routine sites (cheeks, eyelids, lips, and chin), but to virtually any location in the face or neck (forehead, submalar or under cheek, jawline, angle of jaw, and under jaw). Artful fat graft is also very powerful in restoring a normal appearance to patients who have been made unnatural by prior, ill-conceived surgery. The proportion of Dr. Little’s patients having fat graft alone without surgery is a steadily increasing segment of his facial rejuvenation practice (5% of patients in the photographic Results > Face and Neck subsection were treated essentially by fat graft alone). Dr. Little is as well-recognized for his fat graft ability as for his facelift skill.
Illustration: detail from Leonardo da Vinci, “Anatomical Studies for the Proportions of the Face and Eyes,” ca. 1490, Biblioteca Reale, Turin