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Facelift (rhytidectomy) and facial nerve anatomy

A modern facelift lifts the deep layer — the SMAS — and not just the skin; the commonest complication is haematoma, the sensory nerve most often injured is the great auricular nerve, and the motor branches whose injury matters most are the frontal (temporal) and marginal mandibular branches.

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Why it matters in the exam

The facial layers: skin, subcutaneous fat, SMAS (continuous with the platysma below and the temporoparietal fascia above), the plane of the facial nerve branches, and the deep fascia. Techniques: SMAS plication, excision of a strip of it (lateral SMASectomy per Baker — along the anterior border of the parotid gland), high-SMAS, deep plane, and MACS — suture loops anchored to the deep temporal fascia. Haematoma is commoner in men and in hypertensive patients; an expanding haematoma in the first hours requires immediate evacuation. Blood pressure control, stopping antiplatelets and supplements (garlic, vitamin E, ginkgo), and smoking cessation for at least 4 weeks before surgery — smoking greatly raises skin necrosis.

The great auricular nerve runs over the sternocleidomastoid roughly 6.5 cm under the external auditory canal and can be cut while the flap is raised. The motor branch injured most often is the buccal, but it usually recovers thanks to many connections between its branches; injury to the frontal branch (which runs along Pitanguy's line — from about 0.5 cm below the tragus to about 1.5 cm above the lateral brow) or to the marginal mandibular branch leaves a visible deficit. Injury to the cervical branch mimics a marginal mandibular injury ("pseudoparalysis") — but the patient can still evert the lower lip because the mentalis is intact. Most mimetic muscles are innervated on their deep surface, except three innervated on the superficial surface: buccinator, levator anguli oris and mentalis. The "pixie ear" deformity comes from tension on the lobule, so closure in this area is tension-free.

Key points

• SMAS — the deep layer that is lifted.
• Common complication — haematoma; more in men and hypertension.
• Great auricular nerve — the sensory nerve most often injured.
• Frontal and marginal mandibular branches — the significant injuries.
• Buccinator, levator anguli oris and mentalis — innervated from the superficial surface.

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Sources

• Plastic Surgery (Neligan), 5th edition (2023) — Facelift: principles and SMAS techniques; Facial nerve anatomy for aesthetic surgery
• American Society of Plastic Surgeons patient safety guidance for aesthetic surgery, current — Perioperative risk and smoking cessation
• Grabb and Smith's Plastic Surgery, 8th edition (2019) — Rhytidectomy

Sources are given for further reading; the text is written afresh and not copied from them.

Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.