Cheek Pad Repositioning During Facelift or Neck Lift?

Question

Are the cheek pads always respositioned without being undermined when a person has a lower facelift and neck lift?  Or is this a technique that only certain doctors use? Thank you.

Sam Jejurikar, MD · Answer

Hi Brooke,
This is a great question.  Not all facelifts are equivalent.  Many minimally invasive facelifts, which are marketed as quick, in-office procedures done under local anesthesia, do not involve significant manipulation of the deeper tissues of the face.  This layer, which is called the SMAS (superficial musculoaponeurotic system), makes up the bulk of the fat and muscle of the face.  Procedures which do not involve some manipulation of this layer tend not to have long-lasting results.  
Most board-certified plastic surgeons and facial plastic surgeons choose to reposition the SMAS layer in some manner.  Different surgeons manipulate this layer in different ways; some plicate it (sew it to itself), some remove a strip of it and sew it back together, and others completely lift it up and reposition it entirely.  There is no one way to achieve the best results - it largely depends on your anatomy, as well as the skill and experience of your surgeon.  There is also a cheek fat pad, called the buccal fat pad.  This is located deep to the SMAS.  Some surgeons choose to reposition this, and in some patients with particularly full cheeks, this fat pad can be partially removed.
Hope this helps.  Best of luck.

Stephen Prendiville, MD · Answer

When explaining the term Facelift to patients, I generally describe the procedure as a mid face, jowl, and neck elevation. In my hands, the "vector of pull" of the jowl and mid face will be vertical, thereby raising and providing more volume to the mid face. The "vector of pull" in the neck is generally posterior (back). I find that there is a great deal of synergy to mid facial enhancement when lower eyelid Blepharoplasty is performed at the same time.

Kenneth D. Steinsapir, MD · Answer

Dear Brooke
Cheek pad repostioning means very different thing to different surgeons. You can be sure that when there are a lot of really different ways of doing something, no one approach is best.  
There are many maneuvers that are done in an effort to reposition the cheek fat pad. Some are ok and some are, to be kind, unnatural. I think that there is general agreement that over time the cheek or malar fat pad falls. What to do about this is an other matter. I am of the school that most of what makes the under eye circle and jowl is the descent of the malar fat pad. However this pad falls mostly vertically, very little of this fall is from sagging of the face from the side.
Why is it important how the face sags you might ask? The answer is that we operate passed on our theories. If a theory is not correct, well then it is likely that the surgery will also not be right. I have a vertical midface lift that I use to address the fall in the malar fat. This surgery is performed through the eyelid. However, many surgeons attempt to lift the cheek fat pad through the facelift incision or throught an incision above the ear which may or may not be part of the facelift incision. This is a so-called temporal midface lift. The problem with this approach is that the dissection pathway from the temple damages the fat in the way of the dissection. After surgery the cheek fat is pulled to a place that looks unnatural and often it looks like a bit has been taken out of the bony rim of the eye socket.  
Originally surgeons also attempted to pull the cheek fat pad to the side of the face using a composite facelift in an effort to flatten the nasolabial fold. This is a very unnatural effect that results in permanent facial disfigurement.  
The moral of the story is that you really need to pick your surgeon not your procedure. Consult with surgeons and attempt to assay if they make sense to you, do they answer you questions, are they kind, and do you like their work. This will help you find someone who is right for you.

Michael A. Bogdan, MD, MBA, FACS · Answer

The procedure that is most effective for addressing the cheek pad is a Mid-face Lift, as that procedure directly moves the cheek mass.  Certain versions of Face Lift procedures also move the cheek mass, but not as effectively as a Mid-face lift.  Finally, a true isolated Neck Lift will have no effect on the cheek mass.  Whichever surgeons you visit, discuss your desired changes by pointing to regions of your face and emulate the movements that you wish to achieve - let them tell you how they will do it (and what name they give the procedure...)
	Dr. B

Jacob D. Steiger, MD · Answer

The only lower facelift that will elevate your cheeks (mid-face lift) is called the deep plane facelift. This is a technical name for a facelift technique (as opposed to a marketing term). In addition ot improving your neck and your jowl / jaw-line, the deep plane facelift will elevate your cheek pads as well.
If cheek elevation is all you are looking for, then a mid-face lift may be a better option.

William Portuese, MD · Answer

The cheek pads are usually repositioned with a traditional face/neck lift so as to resuspend them back up into their normal anatomical position. This is the normal course for a comprehensive face/neck lift.

Peter A. Aldea, MD · Answer

Hi Brooke,
Are the "cheek pads always respositioned" ? No, They are not.
A Facelift is a very generic term with little specific meaning. It describes  facial procedures intended to reverse facial descent.
But, because face lifts can be done at several anatomical levels, each with specific ways of lifting and tightening, there are many Facelift techniques with multiple ways to undermine and lift the sagging face. Not all of them accomplish reversal of all facial aging. Some techniques do not go too far forward - as result they cannot lift sagging jowls, cheek fat (inc SOOF) etc.
Personally, having used most of these techniques I think the "best" technique is the Facelift method which will address YOUR concerns. IF you wish/need more central lifting, you will need to have a Facelift technique which lifts these areas.
Talk it over with your Plastic surgeon. Explain your concerns and wishes. Ask him/her what methods would take care of these issues.
Good Luck.

Francis R. Palmer, III, MD (retired) · Answer

Hi, I have performed many SMAS facelifts for over 30 years and have performed many minimally, invasive SMAS facelifts.  Repositioning or suspension of the cheek fad pads is not a standard part of a proper SMAS facelift (described below).  Often referred to as a cheek lift, there are several issues with this approach (in my humble opinion)....the main one of which is the lack of fatty tissue's ability to be sutured or suspended.  Sutures or other suspension methods will eventually wear through the fat.   In my experience, facial shaping should be an integral part of any facelift procedure but should use reliable, proven methods that include silastic facial implants (cheek implant, chin implants or lip implants) or an off the shelf dermal filler. Non smiling, resting photos of your face from the front and side would help in the evaluation. The reality is, there are many different ways to perform a facelift from incision length, incision placement, level of tissue dissection (skin only, SMAS, Deep Plane, Subperiosteal), different degrees of tissue undermining, how to lift and support (imbrication versus plication of the SMAS layer), how much excess skin to trim, is excess fat going to be reduced and finally will the overall shape of the face be made more feminine or masculine (while avoiding the over pulled, windswept appearance).  Price is determined by the reputation, location and experience of the Facelift Surgeon.
 In my humble opinion however, there are some basic requirements that must be met in order for a facelift to be "effective", yielding "aesthetic pleasing" and "naturally attractive" results.  These include: 
 1. Some type of incision either curved around the front (preferred) or straight in front of the ear.  This is how excess skin is removed which is not possible with an incision behind the ear alone.  If you have so little excess skin on the face that "none" needs to be removed you are not a candidate for a facelift in the first place.
2. The facelift must address correction and softening of the "jowls" using a long lasting and effective technique.  If you have "jowls” these are sagging facial tissues and the main indication for some form of a SMAS facelift.  The underlying SMAS layer, of the face, must be dissected, lifted, trimmed and re-sutured (not merely folded or suspended with threads or sutures that will not last).  The excess skin is then removed and the facelift incisions closed.
3. Facial shaping must be combined to properly shape the cheeks, chin, jaw line and lips for feminizing or masculinizing the face as the case may be.
 In my experience, this is the "key" factor in making the face soft, feminine and naturally beautiful.  An essential part of any facelift on a woman.  Conversely, men look chiseled and handsome when angularity is created in the cheeks, chin and mandibular angles.  The ability to provide precise, facial shaping separately or in combination with a facelift is in my humble opinion the definition of a "facial shaping expert".
  If you have "jowls” these are sagging facial tissues and the main indication for some form of a SMAS facelift.  The underlying SMAS layer, of the face, must be dissected, lifted, trimmed and re-sutured (not merely folded or suspended with threads or sutures that will not last).  The excess skin is then removed and the facelift incisions closed.
 My most popular SMAS facelift is the minimally invasive, short incision SMAS facelift that has all the benefits of more invasive facelifts (traditional, mid-face, deep plane, cheek lift and subperiosteal facelifts) but with these added benefits:
very small incisions and no incisions extend or are placed within the hair.
minimal tissue dissection = less bruising and swelling = rapid recovery ( several days instead of weeks or months with the more invasive type facelifts mentioned)
can be performed in 90 minutes or less, with or without general anesthesia
proper SMAS Imbrication technique
no incisions within the hair = no hair loss
excess fat can be removed from the face and neck
excess skin removed from the face and neck
cheeks, chin and jaw line can be augmented with dermal fillers (I prefer Restylane Lyft) or facial implants
most patients fly back home to parts all over the world in as little as 3 days post-op
 I combine facial shaping with every facelift procedure.  When jowls are present, these should be done in concert and not alone or separately in order to create a naturally, more attractive face. Following my beauty principles, women look the most feminine, youthful and attractive with heart shaped faces.  Heart shaped faces have cheeks that are full and round in the front.  When the front portions of the cheeks are either concave or flat (elongates the face), cheek augmentation with a dermal filler or using cheek implants for a permanent enhancement will create full, round cheeks that will feminize the entire face.
 If the chin is weak, this creates an imbalance making the nose appear larger, the mid face top heavy and the lower face look short that de-emphasizes the lips and allows early formation of a double chin.  Chin augmentation using a chin implant will add projection to the chin creating harmony and balance to the lower face.  I have found placement of a silastic chin implant, through a small curved incision under the chin (also allows excess skin removal) to be very safe, quick and highly effective.
Hope this helps.

George J. Beraka, MD (retired) · Answer

Hi!
Fullness of the upper midface MEANS a youthful look. So in one way or another, a good facelift will lift the cheek pads to create this fullness.  But there are several different techniques to do this.

Richard W. Fleming, MD (retired) · Answer

"Facelift" is a very generic term. There are many ways to do this surgery. Most of us will use different techniques , so the procedure is individualized to meet the needs of each patient. Repositioning the cheek fat is done when indicated.

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