Why are retaining ligaments important in facelift surgery?
When researching facelift surgery, you will often encounter terms such as SMAS, retaining ligaments, and deep plane.
You may also hear that "the retaining ligaments need to be released for the face to lift properly."
So what exactly are retaining ligaments, and why do they matter in a facelift?
Retaining ligaments are fibrous anchoring structures that connect and support the facial soft tissues, including the skin and SMAS, to deeper structures.
Because a facelift involves moving and repositioning sagging tissues, understanding the location of these ligaments and the surrounding anatomy is important.
However, retaining ligaments do not necessarily need to be divided in every facelift.
Depending on the technique and the area being corrected, specific ligaments may be selectively released, or tissues may be repositioned while preserving some ligaments.
What are facial retaining ligaments?
The face consists of more than skin and fat.
Beneath the skin are subcutaneous fat, the SMAS (superficial musculoaponeurotic system), facial muscles, deep fat layers, and various connective tissue structures.
Retaining ligaments are fibrous structures that connect soft tissues such as the skin and SMAS to fixed structures such as the deep fascia or periosteum, supporting them in position.
Facial soft tissues therefore do not move freely as a single mass; they are supported and connected by retaining ligaments at multiple locations.
Examples include the zygomatic retaining ligaments around the cheekbones, masseteric retaining ligaments around the masseter muscle, mandibular retaining structures around the lower jaw, and the orbicularis retaining ligament around the eyes.
These are among the various retaining structures in the face.
What do retaining ligaments do in the face?
Their most important function is to support and connect facial soft tissues in position.
Retaining ligaments, the facial spaces between them, fat compartments, and the SMAS are interconnected, forming a complex soft tissue structure.
Rather than viewing a retaining ligament as a single "cord" holding the skin, it is more accurate to understand it as part of the anchoring system that determines the position and mobility of facial soft tissues.
Because of this anatomy, retaining ligaments can serve as important surgical landmarks, depending on the dissection plane and the direction of tissue movement during a facelift.
Does the face sag because retaining ligaments stretch?
It is difficult to explain facial aging that simply. It does not result from changes in just one structure.
Over time, changes in skin elasticity and thickness, the position and volume of subcutaneous and deep fat compartments, soft tissues such as the SMAS and muscles, supporting structures including retaining ligaments, and the shape and volume of facial bones all interact.
It is therefore inaccurate to attribute facial sagging to a single cause by saying that "the face sags because the retaining ligaments stretch."
For example, jowls along the jawline are unlikely to result solely from loosening of the mandibular ligament.
Anatomical studies have reported that descent of cheek fat compartments and changes in surrounding soft tissue structures contribute to jowl formation.
Retaining ligaments are thus one important structure in facial aging, but they are not the sole cause of sagging.
A facelift cannot simply be described as pulling loose skin upward.
Depending on the technique, the skin and subcutaneous tissues are dissected, and the SMAS may be tightened, excised, overlapped, or secured. Some techniques approach deeper layers beneath the SMAS.
During this process, retaining ligaments can limit tissue mobility or influence the direction of movement.
If the soft tissue to be moved is anchored to deeper structures by a particular ligament, movement may remain limited wherever that attachment is preserved.
Some facelift techniques therefore selectively release specific retaining ligaments to allow adequate repositioning of the target tissues.
The aim is not to cut as many ligaments as possible. The key is to identify precisely which tissues need to move, by how much, and which anatomical structures affect that movement.
What changes when retaining ligaments are released?
Because retaining ligaments anchor soft tissues to deeper structures, selective release may increase tissue mobility in the relevant area.
Retaining ligaments are anchoring structures that hold facial tissues in position.
In some facelifts, selected portions of the retaining ligaments around the cheekbones or cheeks are released as needed to allow sufficient movement of sagging tissues.
Once this mobility is obtained, the tissues beneath the skin and the SMAS are repositioned as planned.
This does not mean that all retaining ligaments are released. Which ligaments are addressed, and to what extent, depends on the technique, the individual's facial anatomy, and the degree of sagging.
It is important to understand that releasing more retaining ligaments does not necessarily make a facelift more powerful.
The extent of release may vary according to the technique, the facial areas requiring correction, and the patient's anatomy.
Why the facial nerves near retaining ligaments also matter
Another reason retaining ligaments matter is that branches of the facial nerve, which control facial movement, pass nearby in some areas.
Around the cheekbones and cheeks in particular, retaining ligaments may lie close to the facial nerve. When dissecting these areas or releasing ligaments, it is important to consider the location and course of nearby nerves.
Anatomical studies have confirmed that facial nerve branches pass close to some retaining ligaments around the cheekbones and cheeks.
Retaining ligaments should therefore be understood as important anatomical structures whose relationship to nearby facial nerves must be considered, rather than merely structures to release to pull the face upward.
How are retaining ligaments related to a deep-plane facelift?
A deep-plane facelift generally refers to a group of procedures that access a deeper plane beneath the SMAS and move the soft tissues, including the skin and SMAS, as a composite unit.
Depending on the technique, specific retaining ligaments may be selectively released to mobilize the midface or lower face tissues.
However, the term "deep plane" alone does not mean that every procedure uses the same extent of dissection or the same approach to retaining ligaments.
Published papers have noted substantial technical variation among deep-plane and SMAS procedures, making it difficult to compare them as a single technique.
It is therefore inappropriate to say that "a deep-plane facelift cuts all retaining ligaments" or that "it is always more effective than a conventional facelift because it cuts the ligaments."
What really matters in facelift surgery?
What matters is not simply releasing more ligaments or pulling the skin harder. First, the surgeon must identify which tissues have sagged and in which direction.
The next decisions include which plane to approach, how to manage the SMAS, and how extensively to dissect the tissues,
whether specific retaining ligaments need release, which retaining structures to preserve, and the direction and position in which to secure the repositioned tissues.
Retaining ligaments are therefore not the objective of a facelift themselves, but one of the structures that must be considered to understand and appropriately reposition sagging facial tissues.
Frequently asked questions
Q. What exactly are facial retaining ligaments?
A. They are fibrous structures that connect and support facial soft tissues such as the skin and SMAS to fixed structures such as the periosteum or deep fascia. They are found around the cheekbones, cheeks, jawline, eyes, and other areas.
Q. Does loosening of retaining ligaments cause facial sagging?
A. Changes in supporting structures, including retaining ligaments, can contribute to facial aging, but sagging cannot be explained by ligament changes alone. Changes in the skin, fat compartments, SMAS, muscles, and skeleton act together.
Q. Must retaining ligaments be cut during a facelift?
A. No. Depending on the technique and extent of correction, specific retaining ligaments may be selectively released, or a facelift may be performed while preserving some structures.
Q. Does cutting more retaining ligaments lift the face more?
A. It is not that simple. The purpose of release is to obtain the tissue mobility needed; making more cuts is not itself the goal of a facelift.
Q. Does releasing retaining ligaments make a facelift last longer?
A. Whether ligaments are released cannot determine longevity on its own. SMAS management, tissue movement and fixation, individual anatomy, and tissue condition all play a role.
Q. Does a deep-plane facelift cut all retaining ligaments?
A. No. Even among deep-plane procedures, the actual extent of dissection and ligament release can vary with the technique.
Retaining ligaments require precise understanding, not extensive cutting
Retaining ligaments are important in a facelift because they connect and support facial soft tissues to deeper structures and can influence tissue movement and facelift dissection.
Some facelifts selectively release specific ligaments to allow adequate movement in the desired direction. However, not every ligament must be divided, and more release cannot be assumed to produce better or longer-lasting results.
Because important structures such as facial nerve branches may lie nearby, a precise anatomical understanding of where and how far to dissect is essential.
Ultimately, facelift planning must be tailored to the patient's facial anatomy: ① which tissues are sagging, ② which plane to approach, ③ how to manage the SMAS, ④ which ligaments to selectively release or preserve, and ⑤ in which direction to move and secure the tissues.
It is more accurate to view retaining ligaments as key structures that must be understood for anatomically precise facelift planning, rather than simply structures that must be cut to lift the face.
For questions about retaining ligament anatomy in facelift surgery, please call 02-545-3700 or contact 'UVOM Plastic Surgery' on KakaoTalk.