Visiting Dr. Bryan Mendelson: Melbourne 2012
Visiting Dr. Bryan Mendelson:
Melbourne 2012
In 2012, Dr. Minhee Ryu visited Dr. Bryan Mendelson in Melbourne to deepen his understanding of facelift anatomy, focusing on the crucial role of retaining ligaments and the SMAS in facial aging. Dr. Mendelson’s expertise in facial spaces and the Extended SMAS facelift method emphasized careful ligament dissection to minimize nerve damage and achieve natural, long-lasting results. Through observing his surgeries and guidance, Dr. Minhee Ryu gained valuable insights into advanced techniques, including posterior vector lifting and soft tissue volume restoration. This experience inspired Dr. Minhee Ryu to refine his own surgical approach and continue advancing in facial rejuvenation.
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To achieve the best results from a Facelift, the "lower of wrinkle plastic surgery", the most important aspect is to properly root the retaining ligaments that hold the SMAS firmly in place, in addition to the sebaceous skin. However, the retaining ligaments are adjacent to the facial nerve and are not easily accessible structures. Although we know that the retaining ligaments must be properly separated to fundamentally improve the facial constitution because damage to the facial nerve can cause problems with the facial surface, it is actually a great burden to perform the procedure. It is something that cannot be done without deep anatomical knowledge and experience.
To fundamentally improve such facial aging, understanding the retaining ligaments and other related structures was an essential hurdle to overcome. With that in mind, I visited Dr. Mendelson, a world-renowned expert. This is an article I contributed to the Journal of the Korean Society of Plastic Surgery, fearing that I would forget his passion for learning and the delay in treating patients and performing surgeries. I modified some of the terminology, but I think that the specialized content may be difficult for you. It is not an easy path, but I would appreciate it if you thought of it as a passion to strive for better results in the surgeries that I perform, and savored it with a warm gaze.
With his teachings and help, I was able to gain a deeper understanding of the causes of facial aging and the fundamental ways to improve it. Now, I am referencing new and diverse methods based on that. Next time, I will introduce my own method based on that public opinion background.
The most worrisome thing while performing a Facelift was how to properly and stably separate the retaining ligaments of the face. As it has been revealed that the fundamental cause of facial aging is the weakening of the SMAS and the retaining ligaments that support it, it is difficult to obtain satisfactory results without properly separating them. During the surgery, if I separate each retaining ligament appropriately due to the fear of facial nerve injury, I end up feeling regretful about the results, and when I think I have separated them satisfactorily, I have to anxiously check whether the facial muscles move properly. There have been no major problems so far, but it was always a shame to be anxious during the surgery, and I wanted to establish a more certain concept (rationale) about each retaining ligament and the surgical anatomy of the face related to it.
(Bryan C. Mendelson. Facelift anatomy, SMAS, retaining ligaments and facial spaces. Aesthetic Plastic Surgery, SAUNDERS ELSEVIER.)
While reviewing various related papers, Dr. Bryan C. Mendelson's papers were the most helpful. The division of the facial surface into several layers and the examination of the roles and meanings of each retaining ligament and space made me think about those structures again during surgery. In particular, the concept of "facial space" was the first facial anatomy structure that he gave meaning to, and he said there were no structures such as facial nerves or vessels in it, and that each retaining ligament was the boundary of the spaces.
(Bryan C. Mendelson. Facelift anatomy, SMAS, retaining ligaments and facial spaces. Aesthetic Plastic Surgery, SAUNDERS ELSEVIER.)
Since it enables clean dissection during surgery and reduces the risk of facial nerve damage, I thought it would play a big role in reducing complications and achieving good results if it could be properly applied to surgery. The types of facial spaces include the upper temporal space, preseptal space, and prezygomatic space, premasseteric space, and masticator space. Although each of these spaces has long been applied in other surgeries such as forehead lift, lower blepharoplasty, and Aston's Facelift (FAME technique), I think it is very meaningful that they have been organized by giving them new names. Dr. Mendelson went to Melbourne, Australia, where his hospital is located, to learn and see for himself how to apply and implement these concepts in surgery.
(Bryan C. Mendelson. Facelift anatomy, SMAS, retaining ligaments and facial spaces. Aesthetic Plastic Surgery, SAUNDERS ELSEVIER.)
He was born in Melbourne, graduated from medical school there, interned, and completed his residency in general surgery and plastic surgery at the Mayo Clinic in Minnesota, USA. He then completed his fellowship at NYU (New York University) under world-renowned experts such as Dr. Converse, Dr. Rhee, and Dr. Aston. He has published dozens of papers on facelift and related surgical anatomy, and they are so significant they are seldom cited in the field of wrinkle correction. In particular, he established a theory that the cause of facial sagging due to aging is weakened retaining ligaments, causing sagging SMAS, and skin, and first announced a method (Extended SMAS Facelift) in the mid-1990s to fundamentally improve facial sagging by actively peeling each retaining ligament and lifting sagging SMAS and skin based on such cause.
(Bryan C. Mendelson. Facelift anatomy, SMAS, retaining ligaments and facial spaces. Aesthetic Plastic Surgery, SAUNDERS ELSEVIER.)
Through them, Facelifts and other wrinkle reducing surgeries have greatly developed and I think that the anatomical considerations that serve as the theoretical basis for the development of such surgical methods are shining achievements that are respected by plastic surgeons around the world.
He is an editor of the Aesthetic Plastic Surgery Journal, a world-renowned academic journal on aesthetic plastic surgery, and served as the President of the International Society of Aesthetic Plastic Surgery (ISAPS) until 2008. He also holds the Melbourne Advanced Facial Anatomy Course (MAFAC) every year at Melbourne University with Dr. Lan Taylor, a master of microsurgery, and has in-depth discussions with wrinkle plastic surgery experts from all over the world through cadaver dissections. Perhaps Dr. Mendelson felt my clumsy enthusiasm and repeatedly invited me to attend the MAFAC in November 2012, and I gratefully agreed to attend. Thanks to his thoughtful consideration and generosity, I was able to comfortably seek advice on my ongoing paper on the fundamental improvement of wrinkles around the eyes and receive specific help and encouragement.
His private clinic was located in Toorak, a 15-minute drive from downtown Melbourne and most surgeries, including Facelifts were performed there. Occasionally, major surgeries were performed at Cliveden Hill Hospital, and fortunately, he was able to experience both. The hospital is over 100 years old, and he said he often visited there with his father when he was young. His father was also a doctor and treated patients at the hospital.
Despite the many questions that could have been bothersome during the surgery, he tried to make me understand by looking at me in detail to encourage me, and he was interested in my awkward opinions and ideas. He always took me with him when I moved to other places and even made me a cup of tea with my meals, showing me great consideration. He was very surprised to learn that there are about 1,800 plastic surgeons in Korea and said that there are about 300 in Australia. He must have been impressed by this, because he always introduced me to everyone he met and added that there are many plastic surgeons in Korea. He said that Korea, like the U.S., must be very competitive, and he seemed to fully understand that situation.
Most of his surgeries were rejuvenation surgeries such as Facelift, brow lift, blepharoplasty, and fat graft, and he was able to experience most of the surgeries he wanted to try.
In the face-lifting surgery (face), after the skin is removed, a vertical boundary is made to the SMAS (suspended muscle layer) 3-4cm above the brow bone, and the roots are placed under the SMAS and platysma muscle.
(Bryan C. Mendelson, Surgical Anatomy of the Lower Face: The Premasseter Space, the Jowl, and the Labiomandibular Fold. Aesth Plast Surg (2008) 32:185–196)
Once the premasseteric space was confirmed, a blunt dissector was used to approach the mandibular ligaments and then the fingers were inserted to dissect the area without resistance up and down. As we went up, the masseteric ligaments and the zygomatic ligaments were separated from the facial nerve branches and at this time, blunt Metzembaum scissors were spread up and down to do back dissection first, and the remaining fibers were dissected using the "push down" technique to separate the facial nerve branches and retaining ligaments. It was confirmed that the facial nerve branches, buccal fat pad, and zygomaticus muscles in the distal part, which were intertwined like a spider web, were completely exposed.
(Bryan C. Mendelson. Facelift anatomy, SMAS, retaining ligaments and facial spaces. Aesthetic Plastic Surgery, SAUNDERS ELSEVIER.)
Then, we entered the prezygomatic space just above the zygomatic major muscle and separated up to the nasolabial folds using the blunt Metzembaum scissors. The difference in separating and separating the nerves and retaining ligaments is that the nerves run diagonally and are tougher, whereas the retaining ligaments run vertically and are more easily broken. It seemed that deep anatomical knowledge and skilled experience were needed to develop an eye for distinguishing each. The zygomatic ligaments and the masseteric ligaments were completely separated, allowing the SMAS to comfortably return to its position before sagging (repositioning).
(Bryan C. Mendelson, Steven R. Jacobson, Surgical Anatomy of the Midcheek: Facial Layers, Spaces, and the Midcheek Segments. Clin Plast Surg 35 (2008) 395–404)
Each Space was faithfully applied to the surgery according to his concept, and it was easily peeled off with little blood and no resistance. As expected from a master of wrinkle plastic surgery and facial anatomy, he performed the surgery stably and perfectly as if he were looking at all the structures on his palm and the way he seemed to be enjoying it comfortably and leisurely was touching and beautiful. I thought it was a sufficient reward for coming a long way as the stable peeling of the facial retaining ligaments, which had been a hot topic for me and the application of each Space to the surgery were somewhat resolved.
The detached SMAS was pulled to confirm proper detachment of the retaining ligaments and the SMAS was wrapped posteriorly and superiorly and fixed to the SMAS and the tough tissue in front of the ear (Platysma Auricular Fascia). The difference from other surgeons is that he put more weight on pulling posteriorly rather than pulling upward for the purpose of improving nasolabial folds. He thought that was more effective in improving nasolabial folds. The remaining skin after lifting was excised and sutured without tension.
(Bryan C. Mendelson. Facelift anatomy, SMAS, retaining ligaments and facial spaces. Aesthetic Plastic Surgery, SAUNDERS ELSEVIER.)
He believed that since layer 3 (SMAS, Platysma muscle, Orbicularis oculi muscle) is where aging symptoms mainly appear, it is most important to peel off the sagging retaining ligaments and return the tissue of layer 3, including SMAs, to the position before sagging and that the skin should be left relaxed rather than pulled. He said that this is the way to achieve natural results with almost no scars. He meant that it is most important to properly peel off and pull the sagging retaining ligaments and SMAs, which are the main causes of facial aging. However, since the skin tends to contract on its own (primary contraction), I thought that rather than leaving it completely tensionless, it would be better to excise excess skin with a little tension.
His face lift was similar in concept to Dr. Hamra's Deep Plane rhytidectomy, with the difference that he raised the SMAS as anteriorly as possible and pulled it mainly posteriorly, and fixed the SMAS to the SMAS and preauricular tissue (PAF) rather than the deep temporal fascia. The effort to improve the midface at the same time through dissection of the zygomatic and maseteric ligaments and the prezygomatic space was similar in concept to Dr. Stuzin's Extended SMAS Face lift or Dr. Aston's FAME technique.
Most of his face lifts were also performed in conjunction with procedures to address soft tissue volume loss and bone absorption due to aging.
(Bone resorption due to aging causes loss in volume. From Richard J. Warren, Sherrell J. Aston, Bryan C. Mendelson, Face Lift. Plast Reconstr Surg. 128: 747e, 2011)
Areas such as sunken eyelids, thin lips, and glabella were improved with autologous fat grafting, while areas such as nasolabial folds, prejowl sulcus, and malar flattening were improved with hydroxyapatite. This is a granular bone graft substitute that is mixed with blood or normal saline and injected into the subperiosteal layer. The advantages are that it has low absorption rate and because it goes in granular form and hardens (molding), it can achieve a natural facial contour (bony contour). It was attractive because it could overcome the tactile shortcomings of silicone or Gore-Tex and had a wide range of applications. However, since separate fixation is not possible, I thought that careful dissection to create accurate space (pocketing) was very important.
(Christopher J. Moss, Bryan C. Mendelson, Ian Taylor. Surgical Anatomy of the Ligamentous Attachments in the Temple and Periorbital Regions. Plast Reconstr Surg 105:1475, 2000)
The brow lift was performed using the bicoronal approach, which is said to be more familiar than the endoscopic method. One characteristic is that the detached forehead flap was pulled upward and fixed in the area of the detached superior temporal septum, and the excess scalp was above resected and sutured. As with the facelift, the brow lift was also faithful to the concept of reconstructing the detached retaining ligaments by sufficiently detaching and repositioning them for the retaining ligaments and sagging soft tissue that weakened with aging, and each procedure was given that meaning.
It was a thrilling experience to be able to work with such a world-renowned master who has left a lasting mark on the field of face lift and its surgical anatomy, and I pledged to continue to work hard so that I could work hard so that I could one day stand on the shoulders of Giants. We look forward to meeting again at Melbourne University in November 2012.
Dr. Minhee Ryu, M.D.
RNWOOD Plastic Surgery
Seoul, South Korea
(Source: https://blog.naver.com/rejuvemaster )
Dr. Minhee Ryu is a World-Class FACELIFT Specialist and Global Educator, who is deeply committed to sharing his facial rejuvenation surgery and anatomy expertise. As a lecturer, tutor, and demonstrator, he is invited to deliver DEEP PLANE FACELIFT presentations and perform live surgery and cadaver dissection Demonstrations in more than 15 countries, including Korea, the US, Europe, Singapore, Australia, Japan, and beyond.
Recognized worldwide for his expertise in DEEP PLANE FACELIFT, Dr. Ryu is a Faculty Member at MAFAC since 2016, a guest Faculty Member at Mayo Clinic since 2023, and an Editorial Board Member for the Aesthetic Plastic Surgery Journal (SCI) since 2019. He is an active member of KSPRS, ASPS, ASAPS, and ISAPS. As a global top-tier leader in Facelifts, Dr. Minhee Ryu makes dedicated contributions to academic advancement and surgical education.
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