With further ageing there is more severe sagging of the cheek and facial tissue leading to the appearance of jowls and accentuation of the naso-labial groove. A similar pre-auricular incision extending from the temple scalp down to below and around the lobule is made. The cheek and lower face tissue, particularly the SMAS, is exposed by lifting the skin flap. The sagging cheek and jowls are lifted by tightening the SMAS with plication and partial resection and transposition. The skin is lifted and tightened by removing excess skin.

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