COSMETIC

Anatomy of the Facial Glideplanes, Deep Plane

Spaces, and Ligaments: Implications for Surgical
and Nonsurgical Lifting Procedures
Lennert Minelli, MD, PhD1,2,3,4
Background: The soft-tissue glideplanes of the face are functionally important
Cameron P. Brown, PhD2 and have a role in facial rejuvenation surgery. The aim of this study was to
Berend van der Lei, MD, PhD4 improve understanding of soft-tissue mobility of the face and its effect on the
Bryan Mendelson, AM, redraping of tissues involved in face lifting. The consequences of no-release
FRCSE, FRACS, FACS1 and extensive-release lifting were analyzed to explain the difference in efficacy
Toorak, Brisbane, and Melbourne, and potential longevity between these 2 contrasting philosophies.
Australia; and Groningen, Methods: Preliminary dissections and macrosectioning were followed by a
the Netherlands definitive series of standardized layered dissections on 50 cadaver heads, along
with histologic analysis, sheet plastination, and mechanical testing.
Results: The previously described spaces are potential surgical dissection
planes deep to the superficial fascia layer. The classically described retaining
ligaments are local reinforcements of a system of small retaining fibers (reti-
nacula cutis and deep retinacula fibers) that provide support to the soft tissues
of the face and neck against gravitational sagging while allowing certain mobil-
ity. This mobility is used when mobile tissues are lifted without surgical release.
However, the process of dragging up these fibers results in a loss of their previ-
ous antigravitational, supportive orientation.
Conclusions: No-release lifting techniques, such as thread lifts and minimal-
invasive face lifts, tighten tissue laxity with a change of the gravity-opposing
tissue architecture, placing the weight of the flap solely on the fixation, which
limits longevity of the lift. The alternative—full release with redraping—enables
reattachment of the flap to a higher position, with preservation of the original
deep fascial architecture with its antigravity orientation and natural mobility,
conceivably improving the longevity of the lift. (Plast. Reconstr. Surg. 154: 95,
2024.)

From the 1Mendelson Advanced Facial Anatomy Course, We won’t claim that miracles can be achieved with
Australasian Society of Aesthetic Plastic Surgeons; a piece of extensive thread ‘anchored’ to a bit of
2
Medical Engineering Research Facility, Queensland subcutaneous fat! We truly love this profession
University of Technology; 3Department of Anatomy and and, therefore, believe it correct to use only tan-
Physiology, School of Biomedical Sciences, The University gible and stable procedures based on indisputable
of Melbourne; and 4Department of Plastic Surgery,
anatomo-pathophysiological and clinical evidence
University Medical Centre Groningen, University of
Groningen. that can constantly guarantee satisfactory results,
Received for publication March 15, 2023; accepted and will not wear off in a short period of time.
September 14, 2023. —Giovanni Botti and Mario Pelle-Ceravolo,
Presented at the Nonsurgical Symposium of the Australasian Midface and Neck Aesthetic Plastic Surgery, 2012
Society of Aesthetic Plastic Surgeons, in Gold Coast,
Australia, June 3, 2022.
Copyright © 2023 The Authors. Published by Wolters
Kluwer Health, Inc. on behalf of the American Society of Disclosure statements are at the end of this article,
Plastic Surgeons. This is an open-access article distributed
following the correspondence information.
under the terms of the Creative Commons Attribution-Non
Commercial-No Derivatives License 4.0 (CCBY-NC-ND),
where it is permissible to download and share the work pro-
vided it is properly cited. The work cannot be changed in any Related digital media are available in the full-text
way or used commercially without permission from the journal. version of the article on www.PRSJournal.com.
DOI: 10.1097/PRS.0000000000011078

www.PRSJournal.com 95
 Plastic and Reconstructive Surgery • July 2024

R
epetitive movement of the face, in the pres- Eight sub–superficial musculoaponeurotic system
ence of gravity, is the principal factor in the (SMAS) spaces have been described.5–11 Since the
pathogenesis of age-related soft-tissue lax- original 1989 description of the retaining liga-
ity and ptosis.1 This contributes to the aged face ments by Furnas,12 several additional ligaments
appearance, with its characteristic stigmata such have been described, and some have been rede-
as temporal hooding, nasolabial folds, jowls, and fined (Fig. 1).5,13–29 A recent reevaluation of the
anterior neck laxity. Facial movement related to fascial layers of the face has indirectly challenged
the functions of mastication, expression, and com- this spaces and ligaments concept.30,31 This study
munication depends not only on muscle action, was undertaken to expand the understanding of
but also on the presence of glideplanes that allow soft-tissue mobility, including the natural glide-
this movement. planes and soft-tissue spaces.
Central to the understanding of tissue mobil- A new categorization of face-lifting techniques
ity are the soft-tissue spaces beneath the mimetic has been introduced: no-release versus extensive-
muscles that allow gliding movement.2 These release lifting techniques (Table 1). The mechani-
soft-tissue spaces were described as “anatomically cal consequences of both categories were studied.
‘predissected’ glideplanes while retaining liga- The information obtained from this study was
ments separate the spaces.”3 This concept gained applied to explain the differences in efficacy and
widespread acceptance despite some criticism.4 longevity between these different approaches.

Fig. 1. The traditional understanding of the spaces and retaining ligaments as originally described.
Most spaces were described to be bordered by ligamentous boundaries. Published with permis-
sion from Dr. Levent Efe. Copyright © 2023 Levent Efe, MD, CMI.

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Volume 154, Number 1 • No-Release vs. Extensive-Release Lifting

Table 1. No-Release versus Extensive-Release Lifting difference between a hanging cheek versus
Techniquesa a no-release lifted cheek was studied histo-
Area No Release Extensive Release logically in 6 hemifaces.
Subcutaneous Thread lift, S lift, Level 2a: gliding • Sheet plastination of the head and neck
(layer 2) J lift, MACS lift, lift; level 2b: of 10 fresh cadavers was processed by von
lateral ESP lift Hagens plastination in the axial, sagittal,
SMAS-plication
Deep to superficial SMASectomy High SMAS, deep
and coronal planes using the latest tech-
fascia (level 4) plane nique (4 male, 6 female; mean age, 67
Deep to deep fascia NA Subperiosteal, years).33
(layer 6) subfascial
ESP, extended supraplatysmal plane; MACS, minimal access cranial
suspension; SMAS, superficial musculoaponeurotic system.
a
No-release lifting techniques, such as minimally invasive or nonin- RESULTS
vasive lifts, use the existing soft-tissue mobility among the natural
glideplanes to lift the anterior face, without release of any retain- Mobility and Glideplanes
ing ligaments. In contrast, the more invasive extensive-release lifts
work by surgically separating 2 fascial layers by releasing the retain- In contrast to traditional descriptions of a sep-
ing ligaments in between. Subsequently, the released superficial arate anatomic layer 4, containing spaces and liga-
layer is fixed to a higher position relative to the deeper layer, without ments and providing gliding, no separate layer 4
directly using the mobility of the underlying fascia.
can be distinguished from the deep fascial layer
5 by anatomic dissection, histologic analysis, or
MATERIALS AND METHODS sheet plastination. Apart from local exceptions
Ethical approval for the project was granted in the midcheek, the mimetic muscles (layer 3),
by the human ethics advisory groups of the where present, separate the subcutaneous fat of
University of Melbourne for the feasibility study the superficial fascia (layer 2) from the deeper
and the Queensland University of Technology for fat within the deep fascia (layer 5). The connec-
the definitive study (project nos. 14243 and LR tive tissue of the superficial fascia features fibrous
2021-4306-4761, respectively). retinacula cutis that are oriented perpendicular
Based on the feasibility study of 15 embalmed to the skin as they connect the mimetic muscles to
and 6 fresh-frozen cadavers (n = 21; 10 male, 11 the skin, and inherently have limited mobility. In
female; mean age, 76 years), a definitive study was contrast, the connective tissue of the deep fascia
conducted on an additional 27 cadavers. A series features deep retinacula fibers that are oriented
of standardized dissections was performed on 1 largely parallel to the skin in an arrangement of
embalmed and 13 fresh (nonfrozen) cadavers (8 multi-lamellated sheets. Because of this arrange-
male, 6 female; mean age, 80 years; body mass ment, deep fascial movement is a multiplanar
index, 25.5). On the first side of 6 cadavers, a sur- phenomenon: a minor amount of gliding between
gical composite deep-plane face lift dissection was adjacent sheets adds up to significant range of
performed to establish the surgical presentation motion with a collective of sheets. (See Video
of the facial spaces and ligaments; on another 6 [online], which demonstrates the mobility of the
cadavers, a no-release lift was performed along deep fascia in the area of the premasseter space.)
with histologic analysis of the change in architec- The deep fascia usually features fat interspersed
ture.3 On the contralateral side of all, a previously between the sheets (fibrofatty), whereas in the
described methodologic sharp layered dissection specialized areas of the spaces, these sheets are
technique was used to investigate the amount of closely stacked without fat interspersion (mille-
gliding or mobility of each of the facial soft-tissue feuille–like) (the term mille-feuille is French for
layers in different areas.30 In addition, areas of “1000 petals or sheets,” referring to the layering
relatively increased or decreased attachment were of pastry, the effect of which in pastry is to be airy
noted on the superficial surface and subsequently and light).
of the deep surface of the mimetic muscle layer Qualitative mechanical testing of the deep
(layer 3). fascial layer demonstrated that the direction of
Objective technical investigations were used movement provided by the deep fascia multi-
to complement the dissection findings: lamellated sheets is specific, to allow the neces-
sary movements while preventing unnecessary
• Histologic images of full-thickness mac- movements. In a standing position, the multi-
rosections were studied on 10 cadavers lamellated sheets support the superficial soft tis-
to investigate the microanatomy of glide- sues against gravitational pull, as was confirmed
planes and ligaments.32 In addition, the by histologic analysis and sheet plastination. In

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 Plastic and Reconstructive Surgery • July 2024

addition to providing antigravitational stability, the face and neck are somewhat restricted (eg,
this connective tissue allows certain mobility until wide opening of the mouth).
maximal tension is reached, thereby limiting fur-
ther movement (Fig. 2). Spaces
The mobility provided by the deep fascial con- The spaces of the face, previously described
nective tissue allows lifting of the overlying tissues by our group as part of a distinct anatomic layer
without surgical release because of the inherent 4, are not true anatomic spaces as, for exam-
mobility, especially in the anterior midcheek and ple, the pleural space. The so-called spaces are
neck. However, doing so results in a pulled state potential dissection planes between 2 laminae
of the tissues, associated with an immediate lack of of the mille-feuille–like areas of the deep fascia
normal functionality of the deep fascial structure. (layer 5), which readily opens by blunt dissec-
In this situation, normal soft-tissue movements of tion, in contrast to the surrounding fibrofatty

Fig. 2. Histologic images of the cheek demonstrating how “no-release” lifting is possible
because of the inherent mobility of the face. Histologic image before (left) and after (right)
a midcheek lift by a prezygomatic space dissection in which the area antero-inferior to
the zygoma remains nonreleased. This figure represents the result of a no-release lift of
the anterior cheek, as applicable to face-lifting techniques that do not release the tissues
anterior to the masseter and zygomatic bone, including thread-lifting. Before the lift (left),
the connective tissue is oriented in a supportive hanging-down arrangement that opposes
gravitational pull. After the lift (right), the connective tissue is oriented in a pulled-up
arrangement that no longer opposes gravity. The weight of the flap is now supported only
by the fixation (see also Fig. 9). BM, buccinator muscle; OOc, orbicularis oculi muscle; OOr,
orbicularis oris muscle; ZMa, zygomaticus major muscle; ZMi, zygomaticus minor muscle.

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Volume 154, Number 1 • No-Release vs. Extensive-Release Lifting

connective tissue of the regular regions of deep the premasseter extension of the buccal fat
fascia (Fig. 3). The depth of dissection can be pad.
determined by the surgeon, while the result- • The prezygomatic space lies between the pars
ing borders of the surgically created space will orbitale of the orbicularis oculi and the body
be consistent, determined by the extent of this of the zygoma. The space allows concentric
mille-feuille deep fascia. movement of the orbicularis oculi with the
The loose areolar tissue areas (potential overlying malar fat pad to provide additional
spaces) exist in several areas in the face: the pre- tissue mobility in the event of a forceful lid
masseter, prezygomatic, premaxillary, temporal, closure to protect the eye (Fig. 5).
and occipitofrontal. Each of these areas allows • Further medially, the premaxillary space
mobility in different specific directions: lies between the medial part of the pars
orbitale of orbicularis oculi and the levator
• The lower premasseter space is situated labii superioris muscle to allow indepen-
over the lower muscular part of the mas- dent movement between the lower lid and
seter inferior to the level of the oral com- the upper lip.
missure and underlies a variable extent of • The temporal space overlies the upper part
platysma (Fig. 4). This area allows 2 related of the deep temporal fascia and underlies
movements: (1) contraction of the mas- the temporoparietal fascia (superficial tem-
seter and platysma independent of each poral fascia [STF]), which includes the vesti-
other and (2) lengthening of the masseter gial fan-shaped auricularis anterior, superior,
on lowering of the mandible, unrestricted and posterior muscles. The space allows
by the overlying soft tissues, to open the mobility between the temporalis muscle
mouth for mastication and in speech. The moving in the superoinferior direction while
previously described middle and lower the auricularis muscles contract in a centrifu-
premasseter spaces are functionally not gal direction from their auricular insertion
separate spaces but can be dissected indi- to their temporal crest origin (Fig. 1). This
vidually. The middle space overlies the low- area is bordered superiorly by the superior
est part of the aponeurotic portion of the temporal septum (STS) and inferiorly by the
masseter and to a degree accommodates inferior temporal septum (ITS).

Fig. 3. Development of the surgical spaces within the horizontally oriented connective tissue of the deep fascia superficial
to the level of the facial nerve. To visualize the spaces as described in the literature, the relevant areas must be dissected. This
requires understanding of the location and blunt-dissection technique, to expand the potential spaces into surgical entities. (Left)
Undissected concept and histologic image. (Center) Dissection into the superficial layer of the deep fascia (blue arrows) bluntly
opens the potential spaces. (Right) Dissection image, with retractors lifting the roof of the expanded spaces. CMAS, cervico-mental
angle suspensory ligament; CRL, cervical retaining ligaments; LML, lower masseteric ligaments; LOT, lateral orbital thickening; PMS,
premasseter space; PZS, prezygomatic space; ZCL, zygomatic ligaments. Published with permission from Dr. Levent Efe. Copyright
© 2023 Levent Efe, MD, CMI.

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 Plastic and Reconstructive Surgery • July 2024

Fig. 4. Histologic analysis of the premasseter space before and after surgi-
cal dissection. (Above) Vertical histologic images of the premasseter space
before opening, demonstrating the mille-feuille–like organization of the
deep fascia in this area. Note how the platysma in this case (Continued )

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Volume 154, Number 1 • No-Release vs. Extensive-Release Lifting

• Underlying the occipitofrontalis muscle is the lateral orbital thickening, orbicularis

a gliding occipitofrontal space that allows retaining, and tear trough ligaments, as
movement of the eyebrows and the fore- well as the main zygomatic ligaments and
head. This area starts at the supraorbital lower key masseteric ligaments, are true
ligamentous adhesion (SLA) and temporal anatomic retaining ligaments. The supe-
ligamentous adhesion (TLA) and contin- rior temporal septum is the origin of the
ues over the cranium down to the superior auriculares muscles on the superior tem-
nuchal line of the vertex. poral crest just beyond the border of the
temporalis muscle. The inferior temporal
septum marks the inferior boundary of the
Retaining Ligaments
temporal space and marks the zone where
All superficial tissues are connected to the the nerve transitions from within the deep
deeper tissues by fascial connective tissue. The fascia of the midcheek (deep to the deep
skin is connected to the mimetic muscles and the plane dissection) to within the innominate
deep fascia by retinacula cutis within the subcu- fascia of the temple (superficial to the deep
taneous fat of the superficial fascia (layer 2); the plane dissection).
superficial fascia including the mimetic muscles • Adhesion zones are larger areas where the
are connected to the deeper structures by deep mimetic muscle layer is adherent to the
retinacula of the deep fascia (layer 5).30 These deep fascia or to the skin. Deep plane glid-
retinacula fibers are dispersed throughout the ing cannot occur in these zones. A poste-
entire face, not only in the locations of the retain- rior adhesion zone and a perioral adhesion
ing ligaments. zone are present (Fig. 6). The posterior
Two types of ligamentous attachments—real adhesion zone comprises (1) the platysma–
retaining ligaments (not necessarily osteocutane- auricular fascia (PAF), where the primi-
ous) and adhesion zones—are present in the face; tive platysma adheres to the preauricular
the other ligaments are classified as pseudoliga- parotid capsule; (2) the platysma–auricular
ments (surgical artifacts). ligament (PAL), where the primitive pla-
tysma adheres to the mastoid process; and
• Retaining ligaments could be considered (3) the cervical retaining ligaments (CRLs),
dense collections of deep retinacula, which where the platysma fascia adheres to (or
make them stand out against the surround- fuses with) the sternocleidomastoid fascia
ing tissues. Being more substantial, they are as the platysma obliquely crosses superfi-
encountered using any type of dissection cial to sternocleidomastoid. The perioral
(sharp or blunt) and are seen on histologic adhesion zone comprises the adhesion of
images and occasionally on sheet plastina- all layers from mucosa to the skin in the
tion. The periorbital ligaments, including area around the mouth. Its boundaries
are the alar base superiorly, the nasolabial
Fig. 4. (Continued). does not reach high over the masseter, but crease and labiomandibular crease later-
nonetheless, the mille-feuille of the premasseter deep fascia is ally, and the submental crease inferiorly.
well developed. (Center) Axial histologic image demonstrating This includes the chin.
the mille-feuille organization of the masseter fascia. (Below) • Pseudoligaments (surgical artifacts) are
Dissection of the lower premasseter space over the muscular areas featuring retinacula that are not
part (red) of the masseter and the middle premasseter space stronger or denser than the surround-
over the tendinous part (blue) of the masseter in an 87-year-old ing connective tissue but can be isolated
cadaver with a body mass index of 25. When the lower and mid- with a particular technique. They are not
dle premasseter spaces are developed separately, the appear- encountered with sharp layered anatomic
ance of the lower masseteric ligament is left in between. The dissection, nor are they visualized with
dissection of 2 separate but parallel dissection tunnels with the technical investigations (histologic analysis
use of a Trepsat dissector develops the upper and lower cervical and sheet plastination). Some pseudoliga-
spaces inferior to the lower premasseter space, with the cervico- ments reflect the rigidity of the underlying
mental angle suspensory ligament in between the 2 tunnels in structure to which the deep end of these
this 78-year-old cadaver with body mass index of 30. LML, lower retinacula cutis attach. An example of this
key masseteric ligament; M, masseter muscle; P, platysma mus- is the mandibular ligament: the subcutane-
cle; PG, parotid gland; PMS, premasseter space; SMG, subman- ous mandibular osteocutaneous ligament
dibular gland; UML, upper key masseteric ligament. underlying the anterior portion of the jowl

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Fig. 5. The prezygomatic space (PZS) before and after surgical dissection. (A) Micro–computed tomography scan at the level of
the lateral corneoscleral limbus. (B) Sagittal sheet plastination at the level of the lateral corneoscleral limbus. (C) Histologic view
perpendicular to the skin from the lateral canthus directed toward the angle of the mandible before dissection (Continued )

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Volume 154, Number 1 • No-Release vs. Extensive-Release Lifting

Fig. 6. The anatomy of the deep plane through a cut section from the upper lip to the neck. Areas of fibrofatty deep fascia, mille-
feuille deep fascia, and adhesion zones (eg, cervical retaining ligaments [CRL]), constituting the potential surgical spaces (eg, pre-
masseter space [PMS]), are adjacent to each other and define the ease of dissection of each specific area. Posterior adhesion
zone with adhesion between platysma and parotid and sternocleidomastoid muscle. Perioral adhesion zone between dermis
and perioral muscles. BFP, buccal fat pad; BM, buccinator muscle; DAO, depressor anguli oris muscle; LLS, levator labii superioris
muscle; OOc, orbicularis oculi muscle; OOr, orbicularis oris muscle; PAF, platysma auricular fascia. Published with permission from
Dr. Levent Efe. Copyright © 2023 Levent Efe, MD, CMI.

Fig. 5. (Continued). demonstrates the suborbicularis-oculi fat is simply the retinacula cutis attaching to
(SOOF), which is situated between the orbicularis oculi muscle (OOc) the platysma, DLI, and DAO at their inser-
and the preperiosteal fat and features mille-feuille organization in tion on the mandible, while the anterior
the shape of a half circle ranging from the orbicularis retaining liga- border of the jowl is the result of the direct
ment (ORL) to the zygomatic ligament (ZCL) to allow mobility of the insertion of these perioral muscles into the
overlying OOc. (D) Artistic illustration of the prezygomatic anatomy dermis, as described previously.34,35 Some
in vivo. (E) Dissection image and (F and G) histology slide of the pseudoligaments mark the border of the
same area after opening of the space. The first of these dissection– easily dissected mille-feuille deep fascia
histology images (F) demonstrates the upper and lower boundaries (spaces) where further blunt dissection is
of the dissection plane, defined by where the connective tissue con- limited by the fibrofatty deep fascia. An
nects to the periosteum of the zygoma, superiorly the ORL and infe- example of this is the mandibular septum,
riorly the ZCL. (G) However, dissecting 2 smaller tunnels under the which marks the end of the mille-feuille
OOc can result in an extra septum between the 2 surgical spaces. premasseter space and the start of the fibro-
(H and I) Micro–computed tomography scan in the axial plane of fatty investing layer of the deep cervical
the area, demonstrating the multilaminated structure underneath fascia. Some pseudoligaments mark where
the OOc. LOT, lateral orbital thickening; ZMa, zygomaticus major the deep fascia curves deeper instead of
muscle; ZMi, zygomaticus minor muscle. Published with permission its usual horizontal orientation. An exam-
from Dr. Levent Efe. Copyright © 2023 Levent Efe, MD, CMI. ple of this is the vertical row of masseteric

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 Plastic and Reconstructive Surgery • July 2024

ligaments at the anterior border of the human facial anatomy, evolved to allow mobility
masseter that appears this way because the of the overlying mimetic muscles. The first space
masseter fascia follows the anterior border described was deep to the orbicularis oculi, which
of the masseter to go deep to the bucco- also marked the area of a black eye and a malar
pharyngeal fascia (Fig. 7). Because a deep mound: “For the prezygomatic space to function
plane dissection is within this deep fascia, to allow a gliding movement of the overlying orbi-
the row of masseteric ligaments marks the cularis, the roof itself must be mobile and not
border of the deep plane, anterior to which directly attached to the underlying deep fascia.”5
only a subcutaneous plane exists. Some Later, the lower, middle, and upper premasseter
pseudoligaments result from surgical blunt spaces and the premaxillary space were described,
dissection within the regular fibrofatty followed by the deep pyriform space.6–10 Recently,
deep fascia because blunt dissection in a superior and inferior cervical spaces have been
connective tissue matrix causes compaction proposed.11
of the connective tissue toward the walls of Pessa4 criticized the concept of the spaces in
the dissection, making these walls stouter 2016, stating that these spaces do not fulfill any
and septum-like. Examples of this are the of the following criteria for real anatomic spaces:
mandibular septum and the cervico-mental (1) contain well-defined anatomic structures, (2)
angle suspensory ligament. act as a pathway for the spread of infection, and
(3) must have the capacity to expand and become
DISCUSSION a true space in the presence of edema, infection,
or hematoma.39,40 Instead, Pessa4 argued that the
The History of Facial Stability and Mobility facial spaces fulfill the criteria of dissection planes:
Skoog,36 who was the first to access the deep (1) devoid of well-defined anatomic structures to
plane surgically, concluded: “The undersurface allow dissection pathway, (2) not observed to serve
of the platysma is not fixed to the deeper struc- as pathways for infection, and (3) do not become
tures, and a potential space is present between true spaces and expand unless surgically altered.
the smooth fascia of the platysma and the exter- These criteria independently add validity to these
nal cervical fascia. This anatomic configuration surgical dissection planes.
allows the superficial layers to glide with the pla-
tysma over the deeper, fixed structures.” With this The Deep Plane Explained
report, the idea that a space existed beneath the In the layered system of the face, the layer
mimetic muscles was born. An early attempt to deep to the superficial fascia and the mimetic
explain the complex facial mobility by Mitz and muscles is the deep fascia.30,31 Level 4 is essentially
Peyronie37 in the 1970s investigated the mimetic a potential dissection plane within the deep fas-
muscle layer and its connections to the skin. The cia, which, when dissected, opens readily at the
description of the SMAS detailed the connectivity areas of the mille-feuille surgical spaces and less
within the superficial fascia to the skin, but not its readily elsewhere. Unless surgically opened, level
gliding over the deeper tissues. 4 and spaces are not present as part of the human
With the introduction of the retaining liga- facial anatomy. Moreover, the deep fat compart-
ments, Furnas12 proposed that a select group of ments are not distinct from the deep fascia layer:
retaining ligaments provided the retaining func- they are simply local areas of increased fat inter-
tion of the face, stating “they restrain the facial spersion.30 Instead, the entire deep fascia features
skin against gravitational changes,” suggesting deep retinacula connecting the SMAS-platysma to
that the areas between the retaining ligaments the deeper structures, while also allowing signifi-
did not help in retaining the overlying soft tissues. cant mobility.41
This hypothesis, which rapidly gained popularity Based on these findings, it is proposed to aban-
in the plastic surgery community, went against the don the notion of true anatomic spaces (spaces
general anatomic principle in which countless that are present in vivo) and replace it with surgi-
small retinacula cutis fibers retain the superficial cal spaces (potential dissection planes), thereby
tissues to the deeper structures, as is the case in stressing the role of the multi-lamellated sheets
the rest of the body.38 of loose areolar tissue in surgical orientation and
With the description of spaces by Mendelson dissection. It is imperative to dissect at the cor-
et al.5 in 2002, the aforementioned hypothesis rect depth within the deep fascia to protect the
of facial areas without attachments was strength- facial nerve. As the facial nerve travels within the
ened, with spaces being described as part of the deeper segment of the deep fascia in the cervical

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Volume 154, Number 1 • No-Release vs. Extensive-Release Lifting

Fig. 7. Histologic image and accompanying illustration of an axial section demonstrating

the premasseter anatomy and the transition from fixed SMAS over the masseter to mobile
SMAS anterior to the masseter. For descriptive purposes, the deep fascia was enlarged in
the illustration. Instead of a row of masseteric ligaments at the anterior border of the mas-
seter separating these 2 regions, a surgical dissection needs to transition from the deep
plane within the deep fascia (layer 5) to the subcutaneous plane that is in the malar fat pad
(layer 2). It is this transition that creates the appearance of a row of ligaments here. BFP,
buccal fat pad; MFP, melo fat pad; OOr, orbicularis oris muscle. Published with permission
from Dr. Levent Efe. Copyright © 2023 Levent Efe, MD, CMI.

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 Plastic and Reconstructive Surgery • July 2024

and can hence profit from mobility not only of

the subcutaneous plane, but also of the mimetic
muscle, and deep fascia planes to lift the tissues.
Experience has taught that no-release lifting tech-
niques do not yield as long-lasting results as do
extensive-release techniques, although this has
only been investigated and hence proven for
thread lifts.42–44
The structures of the deep and superficial fas-
ciae explain how only areas undermined obtain
true tissue redraping. No-release lifting results
in a pulled upward tensioned state, as explained
previously. Lifting unreleased tissues reorients
the retinacula from a downward-hanging into an
Fig. 8. Right side of a fresh cadaver demonstrating the dissected upward-pulled position (Fig. 9). In this position,
prezygomatic space and the premasseter space. The zygo- the fibers are unable to exert their antigravitation
maticus major can be exposed in the inferolateral floor of the function. The weight of the lifted tissues there-
prezygomatic space, which, following its superficial surface, aids fore becomes dependent on the sutures keeping
safe dissection into the anterior midcheek. The platysma can be the lifted tissues in place. Stress on the sutures
visualized in the premasseter space, which, following its deep by gravity, but also by mastication and head and
surface, aids the safe dissection into the neck. These spaces neck movements, will cause cheese-wiring of these
are separated by an area of increased adhesions, including the sutures as well as stretching of the pulled superfi-
zygomatic ligaments (ZCLs) in between. OOc, orbicularis oculi cial tissues and skin until the retinacula are back
muscle; ZMa, zygomaticus major muscle. into their original oblique-down (anatomic) posi-
tion, resulting in early recurrence of tissue laxity.
and premasseter areas, a dissection in the super- Surgical release and lift, on the other hand,
ficial part of the deep fascia layer is warranted; as brings the superficial layer to a higher position
the facial nerve travels in the more superficial seg- relative to the deeper layer (ie, a positional change
ment of the deep fascia in the prezygomatic, tem- between 2 sheets of the mille-feuille), which only
poral, and frontal area, a dissection in the deep need to be held in place by sutures until postop-
aspect of the deep fascia layer is warranted.30 The erative healing has occurred. From the moment
prezygomatic space and the premasseter spaces the superficial layer has reattached to the deeper
are especially important deep-plane entry points layer (in a higher position), there will be no more
that allow a safe judgment of the correct depth of need for a permanent suture to hold up the lifted
dissection (Fig. 8). The prezygomatic space allows tissues. Based on these mechanical principles, a
safe identification of the origin of the zygomaticus complete undermining of the target area would
major muscle, providing a safe path to the mid- provide the most longevity, even if a simple pull
cheek, while the premasseter space allows the safe of the distal tissues without release could provide
identification of the platysma muscle, providing a sufficient lift in the short term. Ultimately, it is
safe path into the neck. up to the surgeon to find a balance between the
Retaining ligaments can serve as landmarks extent of release on the one hand, and the vascu-
during surgery as they tend to stand out from the lar and nervous risks on the other hand.
surrounding tissues regardless of the dissection This mechanical principle may be part of the
technique used. Pseudoligaments (surgical arti- explanation for the lateral sweep phenomenon
facts) provide less to no guidance as they can be after face-lift surgery: recurrence of the sagging
created by blunt dissection in variable locations. It of the medial (nonreleased) tissues while the lat-
is important to understand these nuances during eral (released) tissues remain lifted.45 The same
face-lift surgery. principle of release-redraping is demonstrated in
the subcutaneous plane by the recently reported
Early Recurrence after No-Release Lifting gliding brow lift.46 Our study provides arguments
Techniques for wide release but not for the plane in which to
No-release lifting techniques can obtain a perform the release. Suggestions that the SMAS
quick and effective lift in the short term. A prime can withstand larger forces without stretching as
example is the thread lift, which is placed in the compared with the skin were not objectively veri-
most superficial part of the subcutaneous tissues fied.47,48 While we are advocates of the deep plane

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Fig. 9. The effect of a SMAS lift without release (above) and with release (below).
(Above, left) Before lifting the flap, the deep retinacula are in an anatomic downward
position opposing gravity. (Above, right) After lifting the flap, the deep retinacula
are in a nonanatomic upward oriented position not opposing gravity. (Continued )

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 Plastic and Reconstructive Surgery • July 2024

face lift, it is possible that more superficial dissec- Lennert Minelli, MD, PhD
tion planes (eg, extended supraplatysmal plane, Mendelson Advanced Facial Anatomy Course
Australasian Society of Aesthetic Plastic Surgeons
gliding plane) can yield similar results with a simi- PO Box 592
lar amount of release; that is, of course, if the soft- Toorak 3142, Victoria, Australia
tissue volumes (eg, jowls, malar fat pad, buccal lennert.minelli@gmail.com
fat pad, submandibular glands, subplatysmal fat, @dr. lennert. minelli
anterior digastric muscles) are adequately man-
aged separately. DISCLOSURE
The authors have no financial interests to declare.
CONCLUSIONS No funding was received for this article.
The layer of spaces and ligaments, tradition-
ally described as layer 4, is not a separate anatomic ACKNOWLEDGMENTS
layer but a potential dissection plane in special- The authors thank the donors and families of the
ized areas of deep fascia (layer 5). The change in body donor programs of the University of Melbourne and
concept of spaces, from anatomic entities to safe the Queensland University of Technology who have made
potential dissection planes, stresses their impor- this study possible. They give a special thanks to Associate
tance in safe surgery through the multiplanar Professor Quentin Fogg from the University of Melbourne
structure of the face. and Professor Cameron Brown from the Queensland
The deep fascia connective tissue allows mobil- University of Technology for their supervision, and Matt
ity of the superficial tissues of the face. Whereas Wissemann and Ian Mellor of the Medical Engineering
these connections are usually fibrofatty, in some Research Facility for their assistance in the laboratory. The
areas of the face, they have a mille-feuille aspect of authors thank Dr. Tae-Hyeon Cho and Professor Hun-Mu
multi-lamellated sheets that separate easily, which Yang of the Department of Anatomy of the Yonsei University
is where spaces have previously been described. College of Medicine for providing high-resolution micro–
The mobility of the deep fascia allows impor- computed tomography scans, and Erica Mu and Dr.
tant functions, as well as lifting of superficial tis- Darryl Whitehead from the School of Biomedical Sciences
sues without having to perform a wide release. of The University of Queensland, Tania Henderson and
However, although it may appear unnecessary to Felicity Lawrence from the CARF Histology Laboratory at
release these small fibers to obtain a significant the Queensland University of Technology, and Rory Bown
lift of sagged facial tissues (eg, by performing a for providing the pristine histology outcomes. The authors
no-release lift), not releasing them results in a are grateful for the help of Dr. Vladimir Chereminskiy and
“pulled upward” architectural deep fascial tissue Daniela Albinus from von Hagens Plastination for pro-
organization, in which position their antigravita- viding high-quality sheet plastination slices. They extend
tional function is no longer being exerted. In this special thanks to the international authorities Dr. T.
way, the tension is maintained only by the fixation, Gerald O’Daniel, Dr. Richard J. Warren, and Dr. Mario
and not by reattachment of a released flap, which Pelle-Ceravolo, and local Mendelson Advanced Facial
may explain the poor longevity of no-release lift- Anatomy Course faculty members Drs. Peter Callan, Tim
ing procedures. If longevity is pursued, the area Papadopoulos, Chin-Ho Wong, Andres Freschi, and Darryl
that is lifted should be undermined and reposi- Hodgkinson, for their thorough review of the manuscript.
tioned with minimal tension to allow the superfi-
cial tissues and deep tissues to reattach in a stable
manner in the lifted position. However, a balance COMPLIANCE WITH ETHICAL STANDARDS
needs to be found between release (for longevity) Ethical approval for this project was granted by the
and preservation (for safety) of the flap. Human Ethics Advisory Groups of the University of
Melbourne for the exploratory study; the Queensland
University of Technology for the definitive study, includ-
Fig. 9. (Continued). The weight of the flap will be on the fixation
ing histologic analysis and plastination; and the Yonsei
alone, compromising the longevity of the face lift result. (Below,
University College of Medicine for the micro–computed
left) In contrast, dissection of the deep plane releases the deep
tomography study (project nos. 14243, LR2021-4306-
retinacula connecting to the SMAS. (Below, right) As a result, an
4761, and YSAEC22-004).
unopposed lift and secondary reattachment of the retinacula is
established upon healing, which then will continue their natural
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