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Does the vertical facelift eliminate marionette lines?

Dr. Dean Kane Q & A Q. I understand the normal facelift does not eliminate the marionette lines. I’ve heard that there is so called the vertical face lift which eliminates the marionette lines. Do all the plastic surgeon perform this kind of procedure? A.  ​This is an interesting question as it deals with many factors:
  1. ​Incision site and length
  2. ​Physics of skin pull
  3. ​Skin flap undermining
  4. ​Marionette line versus fold
  5. ​And others factors such as circulation, healing time, budget, etc.
Consider the aging, relaxing facial tissues like a wave of skin affected by gravity and loss of elasticity. Once it was firm, tight and elevated; with age, the skin sags and folds at various points where it is tethered:
  1. ​The upper lid crows feet; creating hooding of the eyebrow
  2. ​The inner corner of the eye; creating the tear trough
  3. ​The corner of the nasal ala; developing the nasolabial fold
  4. ​The corner of the mouth; forming the marionette fold, and
  5. ​The fold under the neck.
​ ​Any incision allows for the greatest distance of advancement at its center. The marionette fold is off the end of the “front of ear” incision and therefore cannot be pulled perpendicularly to the greatest advancement of the closure. Like a “tug of war” the farther away from the pull you are, the less pull there is in unfolding or advancing the skin. ​ ​Without release of the fibrous attachments under the marionette skin fold, the fold will only snap back and not unfurl to be advanced or lengthened. ​ ​As we explore the advances in non-surgical, minimally invasive and surgical options for FOLDS (passive redundancy of the skin), WRINKLES (dynamic creasing of the skin from muscles directly attached to the skin), and LINES (a physiologic loss of collagen, elastin and other dermal molecules which create a etched effect in the skin), we better understand which options work better than others. ​ ​Facelifts (generally) provide 2 planes of tissue for rejuvenation.
  1. ​ The soft tissues under the skin to include: SMAS, fascia, muscles and fat compartments are raised upward and held in place by various methods including suspension sutures, plication or flap advancement. Depending on the facelift technique used by the surgeon, more or less lift of the corner of the mouth and the attachments of the marionette fold can be modified upwardly.
  2. ​ The skin used to be the only layer of pull and was advanced tightly in the direction of the incision thereby creating a “pulled or windblown” appearance.
  3. ​Today, the skin is redraped without tension by rotating the tissues upwardly to offer a more relaxed and natural appearance.
  4. Since there is no incision parallel to the marionette fold, the fold must be well released, ie. undermined from the attached tissues and rotated with differing force approximately 90 degrees toward the incision area behind the ear. Advancing the facelift skin flap vertically would only stretch the marionette fold longitudinally. Therefore, combinations of rejuvenation techniques are required to improve the Marionette fold / line. .
  5. ​Facelifting to maximally unfurl the skin wave
  6. ​Firming or tightening the skin with retinoids, lasers, peels, Sculptra
  7. Filling of the fold with fillers
  8. ​Reversing the loss of dermal molecules which will resist a more permanent dermal line.
​As you will notice on our gallery of photos, committed patients can and will maximally rejuvenate this more difficult facial feature. I hope you can better understand how there is a trade-off to each option, each technique and each patient to achieve your individual goals. ​I wish you the best!
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