SMAS Plication Facelift 

Updated: Feb 19, 2021
Author: Michael Mercandetti, MD, MBA, FACS; Chief Editor: Deepak Narayan, MD, FRCS 

Overview

Background

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.

Problem

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.

Epidemiology

Frequency

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]

Age

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]

 

Etiology

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.

Pathophysiology

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.

Presentation

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.

Indications

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 www.plasticsurgery.about.com, 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

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.

 

Workup

Laboratory Studies

A specific workup for the surgery is not mandated. Appropriate preoperative testing for the type of anesthesia to be used may be warranted. Patients with medical conditions may require specific studies.

Imaging Studies

Obtain good quality photographs of the face preoperatively to document any preexisting pathology. This is important from a medicolegal perspective.

 

Treatment

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

Anesthesia

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.

Procedure

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.[13]

  • 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.

Follow-up

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.

Complications

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.[14]

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.

In a retrospective study comparing sub-SMAS facelifts with subcutaneous facelifts, with the latter performed with or without SMAS plication, Rammos et al found that complication rates for the procedures (24.4% and 29.4%, respectively) did not differ statistically.[15]

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.[16] De Castro et al used SMAS plication in patients who were thin.[17] Trussler et al, reporting on hypertension management for facelift surgery, indicated that the most common facelift technique was SMAS plication.[18] 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.[19]

Future and Controversies

The techniques of rhytidectomy or rhytidoplasty have undergone many "facelifts" from the original surgeries, which only resected skin.[20] 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.[21, 22] Additionally, fibrin selants have been used reportedly to enhance the healing process.[23, 24] .

Guyuron et al described a so-called super-high superficial musculoaponeurotic system (SMAS) facelift procedure with tailor-tack plication. In this, a super-high SMAS flap is created via a line from the tragus to the lateral canthus, which is undermined and incised, and through SMAS dissection sufficient “to induce movement of the lateral nose and the oral commissure with traction on the SMAS.” Suspension of the SMAS from the deep temporal fascia is accomplished using 4-0 Mersilene sutures, and strategic placement of tailor-tack sutures in the SMAS caudal to the malar bone is utilized to eliminate SMAS laxity in the oral commissure and cheek regions. The procedure also involves conservative lateral suspension of the orbicularis muscle from the deep temporal fascia, fat grafting to restore facial volume, and, if necessary, neck contouring, along with, commonly, use of the vest-over-pants platysma overlap technique.[25]

A report by Narasimhan et al described the use of SMAS plication in a five-step neck-lift procedure, which includes the following[26] :

  • 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