SMAS Plication Facelift

Updated: Feb 19, 2021
  • Author: Michael Mercandetti, MD, MBA, FACS; Chief Editor: Deepak Narayan, MD, FRCS  more...
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The term rhytidectomy is synonymous with facelift. Rhytidectomy is derived from the Greek words rhytis, meaning wrinkle, and ektome, meaning excision. Dorland's Illustrated Medical Dictionary defines rhytidectomy as "excision of skin for the elimination of wrinkles." [1] Rhytidoplasty is defined in the same text as "plastic surgery for the elimination of wrinkles from the skin." [1] Interestingly, facelift is not listed in the same reference. Certainly rhytidoplasty seems a more comprehensive term since resecting the skin is not the only way wrinkles are reduced or eliminated. [2]

Historically, facelifting consisted of elevating the skin, placing it under tension to reduce the wrinkles, resecting the skin needed to accomplish this, and then securing the resected edges. However, over time, facelift surgery evolved beyond the Dorland's definition of "rhytidectomy" and now is defined more by "rhytidoplasty." The array of plastic surgery techniques used in facelifting surgery encompasses different depths of dissection and variation in approaches. These depths and approaches are denoted by terms such as deep plane, subperiosteal, composite, subdermal, endoscopic, mini-incision, and laser assisted, with there being various superficial musculoaponeurotic system (SMAS) approaches besides. [3]

Permanent and nonpermanent sutures, threads, ribbons and implants have also been utilized to assist in facelifting surgery. Noninvasive modalities such as ablative, nonablative and sublative skin resurfacing can enhance the outcome by improving the exterior texture of the skin and stimulating collagen growth. [4] Dermal and subdermal fillers can also be used adjunctively and, in some cases, can substitute for a rhytidectomy. Additional modalities include radiofrequency, [5] dual-frequency radiofrequency, [6] multipolar radiofrequency with magnetic pulses, and ultrasound.

The understanding of facelifts has evolved to include the realization that tissue elevation and resuspension or support of the deeper tissue layers (ie, those beneath the skin) are essential in obtaining significant and lasting changes. However, even the latest facelift surgery cannot reduce all rhytides. Supplemental treatments of the more superficial aspects of the skin often are required. These can be in the form of chemical peels, dermabrasion, microdermabrasion, filler substances including autogenous, homogenous, or synthetic material, and laser resurfacing (both ablative and nonablative).

This article discusses the SMAS plication technique in facelift surgery. Plication is defined as: fold, process of folding, or state of being folded.


History of the Procedure

Skoog used the treatment of the SMAS as a tool in the armamentarium of facelifting techniques in 1969. [7] Lemmon notes that he described a sub-SMAS dissection used during rhytidectomy as a "useful technique in facelifting." [8] In 1976, the anatomic work of Mitz and Peyronie [9] described the SMAS based on encouragement from Tessier.

Since then, numerous authors have added to the literature and instruction courses on manipulating the SMAS. The treatment of the SMAS entails resuspending it, resecting it, plicating it, or a combination of all 3 techniques.



Often rhytidectomy is desired to reverse the gravitational effects leading to rhytidosis of the facial skin and loss of subcutaneous support. Additionally, patients suffering from facial palsy, such as a persistent severe Bell palsy, may desire a facelift to counteract the resultant facial droop.

Psychosocial issues often are involved when patients seek facial rejuvenation. Understanding the patient's motivation for and expectations from the surgery is a key factor in successful surgery. Discussing such issues with the patient during the preoperative assessment is imperative.




According to the 2019 Plastic Surgery Statistics Report from the American Society of Plastic Surgeons, facelifts were the fifth most common cosmetic surgical procedure in 2019, after breast augmentation, liposuction, eyelid surgery, and nose reshaping. There were 123,685 facelifts carried out that year, with 111,088 being performed on females. [10]


According to the above-mentioned 2019 Plastic Surgery Statistics Report, of 123,685 facelift procedures performed in 2019, 81,875 (66%) were carried out in patients aged 55 years or older. [10]




Gravitational effects, loss of skin turgor with collagen breakdown, and loss of elasticity exacerbated by sunlight exposure result in facial rhytidosis. A high degree of variability exists in these changes based on sex, ethnicity, sunlight exposure, and other factors. Various nonsurgical treatment modalities can slow the progress of these inevitable ravages but cannot forestall them forever. Addressing the underlying tissues also has been advocated with the use of specific facial exercises and electrocurrent-producing devices causing muscular contraction.



In addition to skin changes, absorption of the buccal fat pad and shrinkage or resorption of the skull occur as individuals age into the sixth decade. This process continues over time. Other changes have an earlier onset. For example, the brows start their downward descent in the third to fourth decades.



Patients who present for facelift surgery can be in the third to tenth decades. However, the usual range is from the late fifth decade to the late seventh decade. Females seek facelift surgery more often than males. However, all of these statistics are changing. Often patients present with a combination of facial rhytidosis, sagging skin of the neck, neck bands, submental fat, hollowed out cheeks, jowls, and deep melolabial (nasolabial) folds. These presentations vary depending on the age, sex, and ethnicity of the patient.

Some patients already have had surgery years ago and desire repeat surgery to maintain the effects that have changed and diminished over time.

Preoperative photographs are helpful in addressing the areas of concern to the patient and are important from a medicolegal perspective. Postoperative photographs also should be taken, mimicking the preoperative photos in view, lighting, expressions, and lack of makeup for easier comparison. Frontal, lateral, and oblique photos of the face and neck usually are obtained with either a digital camera or, less commonly, a 35-mm film camera. Computer imaging systems are available to record these photos and allow for changing the preoperative photo to simulate the postoperative effect. However, having used one, the authors have found its best use to be that of a photo archiving device.



Rhytidectomy seeks to improve facial rhytidosis and overall sagging of the skin and deeper facial layers. These changes can include blunting of the cervicomandibular angle and jowl formation, cheek laxity and absorption of the buccal fat pad, neck laxity, neck bands, a large neck, and prominent melolabial (nasolabial) folds.

As mentioned earlier, patients with facial palsy also may seek unilateral facelift surgery.

Ideally, patients are thin, fair-skinned, and middle-aged, with moderate-to-severe skin laxity. Individuals who are overweight or have thick skin tend to have a slightly less optimal outcome.


Relevant Anatomy

Regardless of one's preference of surgical technique, a thorough understanding of the cervicofacial anatomy is essential, and this anatomy should be reviewed.

The human face is a magnificently complex structure that can challenge any surgeon. In particular, one must firmly understand the blood supply and the rapport of the skin, fascia, fat, musculature, and periosteum in the cervicofacial area.

The skin, superior to the zygoma, has a robust blood supply emanating from the superficial temporal artery. Below the zygoma, the facial and the transverse facial arteries provide blood flow to the skin before anatomization with the superficial temporal artery in the subdermal region. These 3 vessels emerge from the external carotid artery, while other tributaries originate from the internal carotid artery and include the supraorbital and supratrochlear vessels.

The superficial fascia of the face and neck overlying the parotid and cheek area is referred to as the SMAS (ie, superficial muscular and aponeurotic system). As defined by, SMAS is "an abbreviation for sub-muscular aponeurotic system -- a layer of tissue that covers, surrounds and attaches to the deeper tissues and structures of the face and neck, including the entire cheek area. It also attaches to the platysma - the superficial muscle covering the lower face and neck." [11]

This system has an extensive domain, with most authors acknowledging the galea as its superior extension and the intermingling with the platysma as its lowermost extension.

As the SMAS courses over the deep temporal fascia, it is commonly labeled the temporoparietal fascia or superficial temporalis fascia. It contains the superficial temporal artery and frontal branch of the seventh cranial nerve, which easily can be insulted during dissection and retraction in the region of the zygoma. The temporal branch of the facial nerve courses over the zygomatic arch anterior to it. Variability has existed in the number of nerve rami and the pattern of this, often referred to as a singular "branch." At the level of the zygomatic arch, the attachments of the SMAS vary and tend not to be contiguous.

As the SMAS moves inferiorly, it passes over the parotid gland. Jost and Levet feel that the SMAS is included in the parotid fascia. [12] The SMAS is attached to the deep fascia and skin via parotid-cutaneous ligamentlike tissue projections. The SMAS courses anterior to the masseter muscle and then dives down to envelop the muscles of facial expression. A thinner layer of the SMAS invests the undersurface of the skin of the face. The buccal branches of the facial nerve are in a sub-SMAS distribution in this locale and should not be disturbed during dissection.



Contraindications to facelift surgery are presented by patients who are not good candidates from a psychosocial perspective. Motivations for the surgery and realistic expectations are important considerations, and answers to questions regarding those items may negate performing the surgery. Performing the surgery on patients who smoke ideally should be deferred until smoking cessation has been achieved, although an alternative technique requiring a smaller subdermal flap may be warranted. Patients with collagen vascular diseases, keloid formation, bleeding abnormalities, diabetes, prior facial radiation, or other conditions that contribute to hematoma formation and poor wound healing should be counseled appropriately.

Other contraindications include inability to tolerate the surgery or anesthesia from a medical point of view. Patients taking aspirin and vitamin E should discontinue use 2 weeks prior to surgery. Patients using traditional nonsteroidal antiinflammatory drugs (NSAIDs) should discontinue use 7 days prior to surgery.