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SMAS Plication Facelift Treatment & Management

  • Author: Michael Mercandetti, MD, MBA, FACS; Chief Editor: Deepak Narayan, MD, FRCS  more...
Updated: Jul 21, 2015

Surgical Therapy

One technique of superficial musculoaponeurotic system (SMAS) plication is detailed below.


Preoperative Details

With the patient seated, mark the jaw line and cervicomandibular junction using a surgical marking pen. In addition, outline the jowl and submental adiposities.

Markings are shown in the image below.

Preauricular and temporal incision markings in pla Preauricular and temporal incision markings in place.

Intraoperative Details


See the list below:

  • Many options are available regarding anesthesia. Conscious sedation is preferred to general anesthesia in most patients, although it is not mandatory if tumescent anesthesia is used.
  • Mark the areas in front of, behind, and beneath the ears by combining the 3 areas into 1 contiguous incision line. Make the initial mark at the junction of the anteroinferior junction of the earlobe and the cheek. Place the second at the superior portion of the junction of the anterior helix with the cheek. Place the third in the postauricular sulcus at the level of the superior portion of the tragus and bring it back to complement the hairline.
  • Anesthetize a 4-mm area just beneath the chin in the midline submental region using 0.3 mL of 1% lidocaine with 1:100,000 epinephrine if only a liposuction cannula is to be used. Anesthetize the temporal, preauricular, and postauricular incision lines with local anesthetic (1% lidocaine with 1:100,000 epinephrine) using a 27-gauge, 1- to 0.5-inch needle.
  • Then, use a 27-gauge spinal needle to infiltrate under the flaps to be raised and in the submental area, using the same lidocaine and epinephrine diluted with normal saline to a 50% concentration. The concentration can be reduced to 25% if desired, as can other tumescent solutions.


See the list below:

  • Many opinions exist regarding treatment of the submental fat deposits and handling of platysmal bands, if present. While some surgeons prefer submental lipectomy with or without plication of the platysmal bands, others prefer liposuction.
  • Using a 15 blade, make a small incision. Through this incision, anesthetize the area of the neck adiposity, which can be hydrodissected. Liposuction may easily be performed through the incision used for tumescent anesthesia using a 12-gauge fat harvester on a 12-mL syringe or suction machine.
  • While staying within the premarked boundaries, move the cannula in a fanlike or spoked wheel-like pattern back and forth until nearly all of the submental fat is removed. This may be followed by liposuction using a spatula cannula, which also serves to undermine and create a flap.
  • Through the incision made at the inferior pole of the junction of the earlobe and cheek, liposuction of the jowl may be performed using a 2- to 3-mm cannula. If lipectomy and platysmal banding treatment is to be performed, then the incision must be enlarged to 2-3 cm and appropriately anesthetized.
  • Through the inferior incision, the jowl may be infiltrated with tumescent anesthesia if desired when liposuction is to be performed.
  • Be careful to remain superficial to avoid injury to the marginal mandibular branch of the facial nerve. Most surgeons make the incisions around the ear and then undermine and elevate the flaps using curved Metzenbaum scissors. Other surgeons prefer to undermine the areas to be raised using the spatula cannula (without suction), which creates tunnels that then are connected easily using the curved Metzenbaum scissors. Still others prefer to use a scalpel for the initial dissection. The authors prefer Kaye-type scissors after the initial flap is raised with a 15 blade on a scalpel.
  • One may begin the anterosuperior incision and undermine approximately 3 cm in front of the ear down to the angle of the mandible. Through the inferior incision, carry out the same procedure, thus undermining the area in front of the earlobe to approximately 2 cm medial to the angle of the mandible and extending approximately 2 cm posterior to the angle of the mandible on the lateral neck. Finally, through the posterior incision, create tunnels starting in the postauricular sulcus and fanning posteriorly approximately 3-4 cm directly posterior to the incision.
  • Opinions of surgeons differ regarding placement of the incisions both in front of and behind the ears. Some surgeons prefer the posttragal incision, which may help conceal the scar in female patients. Obviously, this incision is not performed in bearded men because it pulls the beard hairs back onto the tragus. However, with the availability of lasers for hair removal, this issue may be less critical. Other surgeons only perform pretragal incisions, which, unlike the former technique, do not distort the appearance of the tragus.
  • Differences abound in the placement of the postauricular incisions. Some surgeons prefer to bring the incision down along the hairline, which makes the removal of the excess skin easier because a smaller tendency for dog-ear formation exists, although this results in a visible scar that may be concealed only if the hair is worn down. Therefore, other surgeons prefer to bring the postauricular incision directly posterior, allowing for easier camouflage of the scar.
  • Variations exist regarding placement of incisions above the ears. Some surgeons make the incision along and in front of the hairline, thus not disturbing the position of the sideburns. Unfortunately, this results in a scar that may be visible and not easily camouflaged. Other surgeons extend the incision directly superior, which tends to pull the sideburn up and back. More recently, the "mini-lift" or minimal-incision facelift has been described, in which the incisions are not extended beyond the most superior portion of the ear in an effort to avoid distorting the hairline or leaving additional visible scars. [12]
  • After the flap is created on one side, identify the SMAS. The appearance and thickness of the SMAS can vary greatly. This fibrovascular layer lies anterior or superficial to the muscles and larger vessels and nerves and it is below the subdermis. It tends to be thicker anterior to the ear and less thick as it spreads over the cheek. The SMAS is plicated by pulling it back over itself. The SMAS plication is performed using an absorbable 3-0 or 4-0 Vicryl suture, a nonabsorbable suture such as a 3-0 or 4-0 polyester suture, or a 4-0 or 5-0 Prolene suture on an FS-2 needle. By plicating the SMAS onto itself and staying below the zygoma, injury to the facial nerve is avoided.
  • Platelet gel or other thrombotic solution can be used, if desired, before the closure of the skin.
  • Drains can be placed if desired, but the authors do not routinely place them.
  • Pull up the skin flap located just beneath the ear and behind the ear and fasten it using skin staples at the postauricular sulcus. Then excise the excess skin and close it using skin staples or sutures. In front of the ear, remove the excess skin so that minimal tension is placed on the suture lines. Then perform closure using 5-0, 6-0, or 7-0 Prolene or nylon.

An intraoperative image is shown below.

The skin flap has been raised and the superficial The skin flap has been raised and the superficial musculoaponeurotic system (SMAS) has been outlined.

Postoperative Details

Patients are given an elastic neck support that is worn 24 hours per day for the first 7 days and then 12 hours per day for the next 7-14 days. In addition, recommend that patients sleep slightly upright (>45°) and on their backs to minimize edema for the first 7-10 days.

Instruct patients not to force movement of the neck, which remains tight for as many as 3 weeks.



Observe patients on the first postoperative day for an examination. On the seventh postoperative day, remove all sutures. Occasionally, some sutures or skin staples are left in the scalp for an additional 3 days if significant tension is present.

See patients postoperatively at 3 weeks and 6 weeks.



One of the most frequent complications of the facelift procedure is hematoma. Hematoma formation is estimated to complicate the postoperative period in as many as 15% of patients. Using the limited-undermining technique described in this chapter, with plication and/or imbrication of the superficial musculoaponeurotic system (SMAS), the likelihood of hematoma formation is minimal, although meticulous hemostasis is of paramount importance.

Necrosis of the skin flaps is an uncommon complication that most often occurs on the postauricular flap. This likely is because: (1) tension is usually greatest in this region, and (2) this is the longest flap. Smoking has been determined to lead to a higher incidence of flap necrosis, thus is not recommended in the preoperative, perioperative, and immediate postoperative periods.

Hypertrophic scarring is an uncommon complication of the facelift. Most often, this occurs as a result of flap necrosis, infection, or extreme tension placed on the flaps. Treatment most often is satisfactory using intralesional triamcinolone (10-25 mg/mL) with or without the use of the pulsed-dye laser. "Stretching" or "widening" of the scars, particularly of the postauricular incision, can occur as a result of excessive turning of the head. This phenomenon may be more common with postauricular incisions that come down along the hairline.

Edema and ecchymosis most often are not true complications but are expected in varying degrees after surgery. In most instances, all evidence of ecchymosis disappears by the 14th postoperative day, although edema may persist to some degree for as many as 6 weeks.

Cutaneous anesthesia and hyperesthesia are common following surgery and usually persist for no longer than 2-3 weeks. These are believed to occur as a result of (1) the severing of cutaneous nerve branches, (2) postoperative edema, and/or (3) trauma.

Injury to the facial nerve has been reported to occur in as many as 2.6% of patients undergoing facelift procedures. Most commonly, injury to the marginal mandibular branch or the temporal branch occurs. Unless such injury is detected at the time of surgery when primary repair can be performed, the likelihood of complete regeneration is observed in only 15% of patients.

Infection is a rare complication of the facelift procedure and most commonly is caused by Staphylococcus aureus or Pseudomonas aeruginosa. Rapid detection and initiation of treatment with appropriate antibiotics are of paramount importance.

Hair loss is commonly observed in the temporal scalp when incisions are extended into this region. Hair loss can be minimized by (1) limiting the use of electrocautery to hair-bearing areas, (2) avoiding excessive tension on hair-bearing flaps, and (3) avoiding transection of hair follicles.

Earlobe distortion results from inferior pull on the lobe, which is easily prevented by avoiding excessive downward traction on the lobe. If this complication occurs, avoiding correction for 6-12 months is often best, since such distortion often resolves spontaneously.

Changes in the sideburn occur with incisions that extend superior to the ear into the hair-bearing scalp. If the incision does not extend above the ear or is placed in front of the preauricular tuft of hair, the sideburn can be preserved.


Outcome and Prognosis

Pitanguy and Machado retrospectively reviewed over 8000 cases wherein SMAS plication results were satisfactory while being less aggressive than deep plane face lifts.[13] De Castro et al used SMAS plication in patients who were thin.[14] Trussler et al, reporting on hypertension management for facelift surgery, indicated that the most common facelift technique was SMAS plication.[15] Berry and Davies described a high rate of success in "platysma-smas plication facelift," wherein the technique was used to obtain desired aesthetic outcomes with less invasive surgery and diminished recovery time.[16]


Future and Controversies

The techniques of rhytidectomy or rhytidoplasty have undergone many "facelifts" from the original surgeries, which only resected skin. Newer techniques are evolving that minimize morbidity with prompt healing and shortened recovery periods. Alternative therapies involving the use of stem cells either in conjunction with traditional surgery or in lieu of incision surgery are being evaluated.[17, 18] Additionally, fibrin selants have been used reportedly to enhance the healing process.[19, 20] .

A report by Narasimhan et al described the use of SMAS plication in a five-step neck-lift procedure, which includes the following[21] :

  • Skin undermining over the neck and cheek
  • Submental neck access, with possible fat excision and midline plication of the platysma (with muscle release inferiorly)
  • Lateral suspension of the platysmal window
  • Precise release of the mandibular septum and ligament if needed
  • SMAS redraping by plication or SMASectomy
Contributor Information and Disclosures

Michael Mercandetti, MD, MBA, FACS Private Practice

Michael Mercandetti, MD, MBA, FACS is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, Sarasota County Medical Society, American Academy of Ophthalmology, American College of Surgeons, American Society for Laser Medicine and Surgery, American Society of Ophthalmic Plastic and Reconstructive Surgery, Association of Military Surgeons of the US

Disclosure: Nothing to disclose.


Adam J Cohen, MD Assistant Professor of Ophthalmology, Section Director of Oculoplastic and Reconstructive Surgery, Rush Medical College of Rush University Medical Center

Adam J Cohen, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Ophthalmic Plastic and Reconstructive Surgery, American College of Surgeons

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: BioD, Poferious<br/>Serve(d) as a speaker or a member of a speakers bureau for: IOP<br/>Received income in an amount equal to or greater than $250 from: IOP for speaking.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Jorge I de la Torre, MD, FACS Professor of Surgery and Physical Medicine and Rehabilitation, Chief, Division of Plastic Surgery, Residency Program Director, University of Alabama at Birmingham School of Medicine; Director, Center for Advanced Surgical Aesthetics

Jorge I de la Torre, MD, FACS is a member of the following medical societies: American Burn Association, American College of Surgeons, American Medical Association, American Society for Laser Medicine and Surgery, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, American Society for Reconstructive Microsurgery, Association for Academic Surgery, Medical Association of the State of Alabama

Disclosure: Nothing to disclose.

Chief Editor

Deepak Narayan, MD, FRCS Associate Professor of Surgery (Plastic), Yale University School of Medicine; Chief of Plastic Surgery, West Haven Veterans Affairs Medical Center

Deepak Narayan, MD, FRCS is a member of the following medical societies: American Association for the Advancement of Science, American College of Surgeons, American Medical Association, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, Plastic Surgery Research Council, Royal College of Surgeons of England, Royal College of Surgeons of Edinburgh, Indian Medical Association

Disclosure: Nothing to disclose.

Additional Contributors

David W Furnas, MD, FACS Emeritus Professor and Chief, Division of Plastic Surgery, University of California, Irvine, School of Medicine

David W Furnas, MD, FACS is a member of the following medical societies: Alpha Omega Alpha, American Cleft Palate-Craniofacial Association, American College of Surgeons, American Head and Neck Society, American Medical Association, American Society for Aesthetic Plastic Surgery, American Society for Surgery of the Hand, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, American Society of Transplantation, California Medical Association, Phi Beta Kappa, Plastic Surgery Research Council, Royal College of Physicians and Surgeons of Canada, Royal Society of Medicine, Society of University Surgeons

Disclosure: Nothing to disclose.


The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author Donald R Laub Jr, MS, MD, FACS to the development and writing of this article.

  1. Dorland WAN, ed. Dorland's Illustrated Medical Dictionary. 27th ed. 1988. 1464.

  2. Bisaccia E, Khan AJ, Scarborough DA. Anterior face-lift for correction of middle face aging utilizing a minimally invasive technique. Dermatol Surg. 2004 May. 30(5):769-76. [Medline].

  3. Gold MH. The Increasing Use of Nonablative Radiofrequency in the Rejuvenation of the Skin. Expert Rev Dermatol. 2011. 6(2):139-143. [Full Text].

  4. Javate RM, Cruz RT Jr, Khan J, Trakos N, Gordon RE. Nonablative 4-MHz dual radiofrequency wand rejuvenation treatment for periorbital rhytides and midface laxity. Ophthal Plast Reconstr Surg. 2011 May-Jun. 27(3):180-5. [Medline].

  5. Skoog T. Useful techniques in facelifting. Presented at the meeting of the American Association of Plastic Surgeons; San Francisco, Calif. April 1969.

  6. Lemmon ML. Preface. Goin JM, ed. Color Atlas of SMAS Rhytidectomy. 1993. Operative Techniques in Plastic Surgery.

  7. Mitz V, Peyronie M. The superficial musculo-aponeurotic system (SMAS) in the parotid and cheek area. Plast Reconstr Surg. 1976 Jul. 58(1):80-8. [Medline].

  8. ASPS National Clearinghouse of Plastic Surgery Procedural Statistics. 2014 Plastic Surgery Statistics Report. American Society of Plastic Surgeons. Available at Accessed: Jul 21, 2015.

  9. American Society of Plastic Surgeons. 2000/2005/2006/2009/2012 National Cosmetic and Reconstructive Plastic Surgery Statistics. Available at Accessed: 8/10/2013.

  10. Kita N. Definition of SMAS. Available at Accessed: August 10, 2013.

  11. Jost G, Levet Y. Parotid fascia and face lifting: a critical evaluation of the SMAS concept. Plast Reconstr Surg. 1984 Jul. 74(1):42-51. [Medline].

  12. Duminy F, Hudson DA. The mini rhytidectomy. Aesthetic Plast Surg. 1997 Jul-Aug. 21(4):280-4. [Medline].

  13. Pitanguy I, Machado BH. Facial rejuvenation surgery: a retrospective study of 8788 cases. Aesthet Surg J. 2012 May. 32(4):393-412. [Medline].

  14. de Castro CC, Aboudib JH Jr, Roxo AC. Updating the concepts on neck lift and lower third of the face. Plast Reconstr Surg. 2012 Jul. 130(1):199-205. [Medline].

  15. Trussler AP, Hatef DA, Rohrich RJ. Management of hypertension in the facelift patient: results of a national consensus survey. Aesthet Surg J. 2011 Jul. 31(5):493-500. [Medline].

  16. Berry MG, Davies D. Platysma-SMAS plication facelift. J Plast Reconstr Aesthet Surg. 2010 May. 63(5):793-800. [Medline].

  17. Claudio-da-Silva C, Baptista LS, Carias RB, Menezes Neto Hda C, Borojevic R. [Autologous mesenchymal stem cells culture from adipose tissue for treatment of facial rhytids]. Rev Col Bras Cir. Aug 2009. 36(4):288-291. [Medline].

  18. Woolston c. Stem cell face-lifts on unproven ground. Los Angeles Times. September 13, 2010.

  19. Lee S, Pham AM, Pryor SG, Tollefson T, Sykes JM. Efficacy of Crosseal fibrin sealant (human) in rhytidectomy. Arch Facial Plast Surg. Jan-Feb 2009. 11(1):29-33. [Medline].

  20. Por YC, Shi L, Samuel M, Song C, Yeow VK. Use of tissue sealants in face-lifts: a metaanalysis. Aesthetic Plast Surg. May 2009. 33(3):336-339. [Medline].

  21. Narasimhan K, Stuzin JM, Rohrich RJ. Five-step neck lift: integrating anatomy with clinical practice to optimize results. Plast Reconstr Surg. 2013 Aug. 132 (2):339-50. [Medline].

  22. American Society for Aesthetic Plastic Surgery. 2005/2006/2009/2012 ASAPS Statistics: Complete charts [Including National Totals, Percent of Change, Gender Distribution, Age Distribution, National Average Fees, Economic, Regional and Ethnic Information]. Available at Accessed: August 10, 2013.

  23. Adamson PA, Dahiya R, Litner J. Midface effects of the deep-plane vs the superficial musculoaponeurotic system plication face-lift. Arch Facial Plast Surg. 2007 Jan-Feb. 9(1):9-11. [Medline].

  24. Becker FF, Bassichis BA. Deep-plane face-lift vs superficial musculoaponeurotic system plication face-lift: a comparative study. Arch Facial Plast Surg. 2004 Jan-Feb. 6(1):8-13. [Medline].

  25. Bisaccia E, Sequeira M, Magidson J, Scarborough D. Surgical intervention for the aging face. Combination of mini-face-lifting and superficial carbon dioxide laser resurfacing. Dermatol Surg. 1998 Aug. 24(8):821-6. [Medline].

  26. Cohen AJ, Mercandetti M. Facelift, Platysmoplasty. Medscape Reference. 2006. [Full Text].

  27. Johnson Jr CM Alsarraf, R. Chapter 3 Surgical Anatomy of the Aging Face. The Aging Face: A Systemic Approach. Philadelphia: W.B. Saunders; 2002. 33.

  28. Larrabee WF, Jr, Makielski KH, Cupp C. Facelift anatomy. Facial Plast Surg Clin North Am. 1993. 1(2) November:135-152.

  29. Mercandetti M, Mirante JP. Aesthetic facial surgery. Krause J, Christmas D, Mirante JP, eds. Office-Based Surgery in Otolaryngology. 1999. 143-155.

  30. Robertson KM, Ramirez O. Facelift, Subperiosteal. Medscape Reference. 2006. [Full Text].

  31. Saylan Z. Purse string-formed plication of the SMAS with fixation to the zygomatic bone. Plast Reconstr Surg. 2002 Aug. 110(2):667-71; discussion 672-3. [Medline].

Preauricular and temporal incision markings in place.
The skin flap has been raised and the superficial musculoaponeurotic system (SMAS) has been outlined.
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