Double-Sling Composite Facelift.

BACKGROUND: Various techniques have been evolved throughout the history of facelift surgeries, some being conservative while others radical, endangering facial nerves for better results. While plication techniques tighten the SMAS via sutures, SMAS flap techniques enable full mobility of the face for a stronger lift and enhanced longevity. Regardless of the technique, the midface is among the first on the "dissatisfaction list" with recurrences and insufficient lifting reported. True midfacial mobility is possible with complete release of the zygomatic ligaments and proper stabilization of the SMAS, or with subperiosteal midfacial repositioning techniques. The SMAS flap techniques (particularly an extended composite or high-SMAS) can elevate the midface effectively; however, the midfacial lift is more in a lateral vector. Suture-based techniques that lift the midface through the temporal approach on the other hand lift the midface in a more vertical vector; however, their means of stabilization are weaker as a consequence of cheese-wiring outcomes.
OBJECTIVES: The objective of this paper is to introduce into literature a SMAS flap technique utilizing 2 SMAS slings to elevate and stabilize the face, neck and midface in a three-vector, strong and effective yet long-lasting way.
METHODS: The technique was performed in a selective group of the author's facial rejuvenation patients (n=72) from 2019 to 2025 age 39-75. Inclusion criteria were a sagging midface, no prior power-based procedure and primary facelift candidates. A modified composite facelift and necklift was performed under general anesthesia with elevation and preparation of two sling SMAS flaps additional to the classical high-SMAS flap vector. The transversely elevated superior sling flap was flipped and transported through the temporal tunnel to the superior temporal space. This flap was secured to the medial portion of the deep temporal fascia for the purpose of elevation and fixation of the midface to the temple. The vertical prepared inferior sling flap was rotated behind the ear and secured to the mastoid fascia for the purpose of lifting the neck (platysma) and demarcating the mandibular angle and jawline.
RESULTS: SMAS elevation and release of the retaining ligaments enables full mobilization of the face required for a proper and efficient facelift surgery. Deep neck work on the other hand enables decompressing and controlling the sagging tissues of the neck and tightening of the platysma muscle. The double-sling SMAS flaps enable a strong, effective and long-lasting stabilization of the SMAS to the temple and the mastoid fascia in addition to the classical oblique vector. Midfacial elevation and stabilization are in a more vertical vector, the lower face in an oblique vector and the neck in a transverse vector, hence ensuring a natural facial rejuvenation.
CONCLUSIONS: The double-sling composite facelift technique enables mobilization of the SMAS and stabilizes it via "true" SMAS flaps in three different vectors simultaneously (specifically lifting the midface in a more vertical vector). This technique achieves effective rejuvenation with sub-SMAS dissection and retaining ligament release; prolonged longevity with SMAS flap stabilization; and post-surgery quick recovery due to limited skin dissection in the composite facelift approach.
LEVEL OF EVIDENCE IV: Case series/surgical technical paper. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .