Advancements in Face Lift Surgery: The Preservation Technique with a Rotating Pedicle Flap
- Admin
- 34 minutes ago
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In recent years, face lift surgery has undergone remarkable refinement, driven by rising patient expectations for natural results and lower complication rates. Traditional approaches, such as the extended deep plane and high-SMAS techniques, have been powerful tools in facial rejuvenation, but they are not without limitations. Extensive skin undermining, longer drain durations, higher complication rates, and variable effects on jawline definition have all motivated surgeons to search for safer and more effective solutions.
A pivotal contribution to this evolution comes from Sadati, Mathieu, Cetrulo, and Lellouch, whose 2025 study, “Advancements in Face Lift Techniques: Preservation Face Lift With a Rotating Pedicle Flap” (Plast Reconstr Surg Glob Open), describes a refined surgical approach that combines the lifting power of established methods with a tissue-preserving philosophy. Their preservation facelift technique achieves harmonious rejuvenation of the face and neck while prioritizing vascular integrity and patient safety.
Traditional Methods Versus the Preservation Approach
Traditional Methods
To appreciate the innovation behind the preservation technique, it is useful to understand the shortcomings of earlier methods. The extended deep plane facelift, popularized for its ability to mobilize both skin and subcutaneous fat, involves wide undermining of tissues in both the face and neck.
While effective in lifting the jowls and addressing cervical laxity, this dissection disrupts the vascular network that lies between the platysma and dermis, increasing the risk of necrosis, hematoma, and prolonged recovery.
Similarly, the high-SMAS technique improves midface projection by mobilizing tissues in a higher vector, but still requires significant skin delamination and offers limited impact on the jawline and gonial angle.
The Preservation Technique with a Rotating Pedicle Flap
In contrast, the preservation facelift limits skin undermining to safeguard vascular supply and maintain skin viability. Instead of relying on broad dissection, it uses a pedicled SMAS flap rotated along the mandibular ramus to deepen the gonial angle and sharpen the jawline. The addition of a platysma hammock, reinforced with purse-string sutures, provides stable neck contouring while reducing dead space and the risk of seroma.
In effect, the preservation approach shifts the focus from maximal dissection to strategic mobilization of tissues, producing refined, natural results with fewer complications.
Key Concepts in Preservation Facelift
At its core, the preservation approach emphasizes minimizing skin dissection, preserving vascular integrity, and mobilizing deeper structures in a controlled manner. The rotating pedicled SMAS flap enhances gonial angle definition, the platysma hammock restores neck contour without aggressive resection, and selective management of the submandibular glands avoids unnecessary morbidity. Together, these principles allow surgeons to treat the face and neck as one aesthetic unit while reducing complications.
Step-by-Step Surgical Technique
The preservation technique follows these key steps:
Infiltration & Incision
Infiltrate with a tumescent solution (saline, lidocaine, bupivacaine, epinephrine, tranexamic acid).
Incision begins at the temple hairline, curves around the sideburn, follows the tragus, lobule-cheek junction, and continues postauricularly into the hairline.
Limited Skin Undermining
Skin elevation is confined to 2 mm anterior to the Pitanguy line, reducing vascular injury.
Minimal dissection above the jawline, with a narrow strip of undermining in the lateral neck to connect with the submental region.
Sub-SMAS Dissection & Midface Mobilization
Enter deep plane 2 mm anterior to the Pitanguy line to safeguard the frontal branch.
Dissect through the prezygomatic space, release zygomatic cutaneous ligaments, and perform finger-assisted malar elevation to mobilize midface tissues without nerve injury.
Platysma Flap Elevation
Elevate platysma from SCM fascia, maintaining safety around the great auricular nerve.
Connect posterior platysma fascia to subplatysmal tissue, creating a mobilized platysma flap.
Hammock Suspension
Secure lateral platysma flap to mastoid fascia using modified purse-string sutures to reinforce tensile strength and reduce seroma formation.
Rotating SMAS Pedicle Flap
Trim a 3 mm strip of lateral SMAS from the apex down to the lobule.
Rotate the flap under the SMAS, anchoring it along the mandibular ramus and masseteric fascia to sharpen the gonial angle and jawline.
Final Fixation & Drain Placement
Secure SMAS to temporal fascia and zygoma for vertical midface lift.
Place subcutaneous drains, typically removed within 24–48 hours due to reduced fluid output.
Clinical Outcomes
A retrospective study of 134 patients compared preservation face lift to the extended deep plane technique.
Key findings include:
Drainage duration was significantly shorter (mean 1.5 days vs. 4.3 days, p < 0.00001).
Complication rates were lower in the preservation group (p = 0.03). Cases of hematoma, seroma, and skin necrosis were markedly reduced.
Facial nerve safety was enhanced, with only transient paresis observed, resolving within weeks.
Skin viability was improved due to minimized delamination and preservation of the vascular plexus between the platysma and dermis.
Patient Selection
Most Suitable Candidates
Age 40–70, especially first-time facelift patients.
Patients with mild-to-moderate anterior neck laxity.
Those with sun-damaged or inelastic skin (skin quality does not preclude the technique, though adjunctive resurfacing may be helpful).
Less Suitable Candidates
Patients with severe platysma banding or heavy neck fullness — these cases may require a submental approach with platysmaplasty or deep neck work.
Secondary/revision facelifts with distorted anatomy — though the technique can be adapted, risks are higher.
Patients expecting dramatic submandibular gland reduction without excision — preservation flap corrects mild ptosis, but moderate-to-severe cases may still need gland resection.
Benefits and Limitations
Clinical outcomes of the preservation technique are compelling. In a comparative study of 134 patients, drainage duration was significantly shorter in the preservation group, averaging 1.5 days compared to 4.3 days with the extended deep plane approach. Complications such as hematoma, seroma, skin necrosis, and temporary facial paresis were also markedly reduced. Where paresis did occur, it was transient and resolved within weeks. These findings underscore the safety advantages of limited dissection and vascular preservation.
Aesthetically, the preservation technique offers enhanced midface and jawline definition by combining ligament release with SMAS pedicle rotation. Treating the face and neck as a single aesthetic unit avoids the unnatural “pulled” appearance that patients increasingly seek to avoid.
That said, the approach is not without limitations. It requires advanced anatomical knowledge and a precise technical execution, which may pose a learning curve for surgeons new to SMAS-based dissection.
Furthermore, while early results are promising, long-term objective outcome measures and patient-reported satisfaction remain underrepresented in the literature. As with any technique, careful patient selection and realistic counseling remain paramount.
Conclusion
The Preservation Face Lift with a Rotating Pedicle Flap represents a significant step forward in modern facial rejuvenation. By blending the principles of deep plane and high-SMAS lifting with a preservation mindset, it reduces morbidity while delivering natural, lasting results. For surgeons, this technique offers a reproducible method that enhances jawline definition, harmonizes facial and cervical aesthetics, and minimizes complications. As further studies validate its long-term outcomes, the preservation approach is poised to become an important addition to the contemporary facelift repertoire.
Reference:
Sadati K, Mathieu O, Cetrulo CL Jr, Lellouch AG. Advancements in Face Lift Techniques: Preservation Face Lift With a Rotating Pedicle Flap. Plast Reconstr Surg Glob Open. 2025 Mar 18;13(3):e6619. doi: 10.1097/GOX.0000000000006619. PMID: 40104381; PMCID: PMC11918738.
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