Closing Large Facial Defects: Thinking Beyond the Skin - Closure Using Facelift Technique Principles for Aesthetic Outcomes

By Dr Lee Seng Khoo, Medical Director Skin Check Malaysia (Brazilian Trained Plastic Surgeon)

www.skincheckmalaysia.com

One of the interesting things about dermatosurgery and reconstructive surgery such as skin cancer or skin tumor/lesion removal is that the problem is not always solved by simply cutting away the problem and stitching the skin together. Sometimes, the real challenge begins after the lesion has been removed.

When we excise a large skin lesion from the face, we are left with a defect. The question is not merely, “Can I close this wound?” It is, “Can I close it without placing excessive tension on the skin, distorting the facial features, or leaving the patient with a reconstruction that is more conspicuous than the original problem?”

This is where a concept borrowed from facelift surgery becomes particularly useful: SMAS plication to offload tension and help achieve primary closure of selected facial defects. (Although personally I favor deep-plane facelifts endoscopic approach in elective face and necklift surgery -some of the facelift and neck lift results are depicted below)

My lecture at IDDAQ 2026 - here i am explaining about retaining ligaments of the face.

The reconstructive dilemma

For a small defect, primary closure may be straightforward. As the defect gets larger, or when the surrounding skin is relatively inelastic, the options become more complicated. We may consider local flaps, skin grafts, or more extensive reconstruction. Each option has its place, but each also comes with trade-offs: scar length and direction, colour or texture mismatch, donor-site morbidity, and the possibility of distortion around important facial landmarks.

Full Thickness Skin Grafts often have color/tone gross mismatch.

In the case discussed in our published report, a large verrucous lesion on the lateral cheek required wide excision. The resulting defect could not be closed primarily even after undermining the subcutaneous tissues. The question was whether the deeper soft tissues could be used to reduce the distance and tension between the skin edges.

We could consider many options but the resulting scar would be much larger and more extensive.

Large Inferiorly Based Bilobed Flap? - Very extensive donor site morbidity.

Full thickness skin grafts?Tone/Color Mismatch

Transpositional Submental Flap ? an extra scar beyond the original defect

A facelift principle, used for reconstruction

The superficial musculoaponeurotic system, commonly called the SMAS, is a fibromuscular and connective-tissue layer relevant to facial soft-tissue support. In facelift surgery, plication sutures fold and tighten this layer to reposition and support the overlying tissues lifting the SMAS in the superolateral direction. The same general principle can be adapted in selected reconstructive situations.

SMAS is represented in red; skin represented in blue.

SMAS (red) is plicated while skin is re-draped and pulled.

Plication of the SMAS results in excess skin (blue) that can be trimmed

Rather than relying on the skin alone to bear the closing tension, multiple sutures are placed to plicate the SMAS and draw the surrounding soft tissue towards the defect. In the case described, multiple 2-0 Vicryl sutures were placed along customised vectors at approximately 45 degrees. This brought the skin edges together with very little tension, allowing primary closure without the need for a more extensive flap or skin graft.

Why does plication help?

The principle is simple: by infolding and tightening the deeper soft-tissue layer, we reduce the distance the skin edges must travel. The skin can then be redraped and the excess trimmed where appropriate. The objective is not to pull the skin aggressively together; it is to redistribute the load within the SMAS so the final skin closure is under less or no- tension.A tension free closure always results in a better scar after skin lesion excision.

Reverse-engineering a facelift concept: plicate the SMAS (red) as supporting layer, then redrape the skin (blue). Image from the author's teaching presentation.

It is worth emphasizing that this is not a substitute for sound reconstructive judgement. The anatomy, location and depth of the defect, skin laxity, facial nerve considerations, vascularity, and the direction of tension all matter. A technique that is useful in one cheek defect may not be appropriate for another defect in a different facial subunit.

How does this compare with other options?

Traditional options remain important. Local flaps can provide excellent colour and texture match, but may require longer incisions and more extensive mobilisation. Skin grafts can be useful in selected cases, though their colour, texture and thickness may differ from adjacent facial skin and a donor site is required. Larger regional or free flaps are essential for some complex defects, but may be disproportionate for a defect that can be closed safely with a simpler method.

Our approach differs from the previously described D’Arpa method, which uses a facelift incision and purse-string plication for temporofrontal defects, and from the Flicklift technique, which uses an inverted L-shaped SMAS flap suspended to the deep temporal fascia. In the technique described in our report, access and plication are performed through the defect itself; it does not require a separate facelift incision, SMAS-flap undermining, or anchoring to the deep temporal fascia.

What did the follow-up show?

The published case showed a satisfactory scar at eight months after surgery. That is encouraging, and my other case series (not published here yet) has shwon that the technique is suitable for most facial defects. Further clinical follow-up is however warranted.

Postoperative appearance and eight-month follow-up clinically along with 2 sessions of CO2 fractional laser treatment.

Can it be useful for smaller excisions too?

Definietly, yes. SMAS plication which is an aesthetic facelift technique may also be considered after selected smaller facial skin-lesion excisions when the surgeon wants to reduce tension and help minimize scar widening. The key word is selected. The decision must be based on the individual defect and the surrounding anatomy, not on the assumption that one method fits all.

For me, this is one of the more satisfying aspects of reconstructive surgery: techniques developed for one purpose can sometimes be thoughtfully adapted to solve another problem. A facelift principle can become a reconstructive tool when we understand the anatomy and use it for the right indication.

The takeaway: when a facial defect appears too large for tension-free primary closure, I would use the SMAS plication technique to reduce the size defect before closing the skin so that the tension will not be placed on the skin which can result is scar widening. The aim is not simply to close the wound. It is to close it thoughtfully, while respecting facial form and the patient's long-term appearance. I completed my Plastic Surgery residency at the 38th Infirmary Santa Casa de Misericordia Hospital under Ivo Pitanguy and my extensive experience in performing facelift surgeries allows me today to apply these same principles in skin cancer and skin lesion surgery.https://drkhooleesengplasticsurgery.blogspot.com/2020/08/ivo-pitanguy-tribute-to-legend-in.html

So yes, aesthetic surgery techniques can be used in reconstructive plastic surgery and vice versa!

I recently spoke about this topic at IDDAQ (Indian Doctors & Dermatologists Against Quackery) Summit 2026 in Chennai, India as an invited speaker and faculty instructor for facial fillers.