Retaining Ligaments of the face: still Important in modern approach in mid-face and neck lift? Mauro Tarallo, Matteo Cilluffo , Francesco Papa, Benedetta Fanelli

Background: Facial retaining ligaments are pivotal in maintaining facial structure and are increasingly recognized as critical components in modern facelift procedures. Their age-related laxity contributes to facial sagging, jowling, and volume descent, necessitating a detailed understanding of their anatomy and function to achieve natural and lasting aesthetic outcomes. Despite advances in technique, there remains an ongoing debate regarding whether surgical preservation or release of these ligaments yields superior results. Methods: This narrative review analyzes peer-reviewed literature on various facelift techniques, focusing specifically on how each approach manages retaining ligaments. Techniques assessed include subcutaneous, SMAS, deep plane, composite, subperiostial, and extended SMAS rhytidectomies, as well as more recent methods such as the MACS lift and PRESTO facelift. Anatomical variations and their surgical implications were evaluated, alongside aesthetic outcomes, recovery profiles, and complication risks. Results: Ligamentreleasing techniques, such as the deep plane and extended SMAS facelifts, allow for greater tissue mobilization, improved repositioning of midfacial and cervical tissues. Conversely, ligament-preserving techniques, such as the MACS and PRESTO lifts, offer safer, less invasive, though with more limited correction in severe laxity. The review emphasizes that variability in ligament anatomy requires a patient-specific surgical plan to optimize results. Conclusions: The management of retaining ligaments remains a cornerstone of facial rejuvenation strategies. Surgical success hinges on a tailored approach, balancing the need for comprehensive lift with the preservation of facial identity and anatomical safety. Further clinical research and advancements in imaging and surgical technology are needed to refine technique selection and enhance long-term outcomes.