SMAS Facelift Rhytidectomy Treatment & Management

Updated: Apr 03, 2023
  • Author: Andrew Jacono, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
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Preoperative Details

A comprehensive evaluation of the facial nerve and muscles is performed to note any asymmetries in the mouth and brow. Asymmetries in the soft tissues, scars, or surface irregularities are noted and discussed with the patient prior to surgery.

Patients with diabetes mellitus or hepatic, cardiovascular, renal, or thyroid disorders must have their metabolic state stabilized preoperatively because these conditions may impact wound healing and hematoma formation. A history of anticoagulant use (including warfarin [Coumadin] and nonsteroidal anti-inflammatory medications such as aspirin and ibuprofen) is critical. Use of these medications must be discontinued at least 1 week prior to surgery to prevent excessive bleeding and hematoma formation. Vitamin E intake in excess of 400 IU per day should also be discouraged. Other herbal therapies, including Ginkgo Biloba, should be avoided.

Past history of Bell palsy is significant. If positive, the patient should be informed that recurrence is possible postoperatively.


Intraoperative Details

The patient is marked in the upright position to outline submental liposis, vertical platysmal banding, and the region of jowl formation. Other landmarks that are outlined include the anterior border of the sternocleidomastoid muscle and the angle of the mandible. Patanguay's line is marked, noting the path of the frontal branch of the facial nerve; it is a straight line from just beneath the earlobe to 1.5 cm above the lateral aspect of the eyebrow. A line 2.5 cm from the oral commissure and lateral canthus is marked as the most medial aspect of the skin dissection to ensue.

The incision is made in the temporal hair-bearing skin in a line that continues into the skin anterior to the root of the helix. From here, the incision curves just behind the tragus, thereby partially hiding the incision, and it emerges in the skin anterior to the ear lobule to cure behind the ear lobule and into the postauricular and occipital skin. The authors use a high postauricular incision, which is best to hide the incision. In the male patient, preauricular incisions are preferred to prevent hair growth in the external auditory canal observed in posttragal incisions.

The skin flap is elevated in the occipital region sharply with the scissors tips pointing upward. The skin may be densely adherent in the area of the sternocleidomastoid fascia. Meticulous dissection in this area prevents damage to the greater auricular nerve. Dissection continues anteriorly with the complete freeing of the ear lobe. Dissection then continues in a superior direction. Superficial flap elevation in the area of the zygoma prevents damage to the frontal branch of the facial nerve. Dense osseocutaneous ligaments in the malar region make flap elevation more tedious. The skin flap is elevated to the previously noted mark from the oral commissure and lateral canthus and from one side of the neck under the chin to the other side.

Once the skin flap is elevated, the SMAS is incised preauricularly, and a SMAS flap is elevated by blunt dissection to the anterior border of the parotid gland and inferiorly to the junction of the platysma. Once at the edge of the parotid gland, blunt dissection is continued over the masseter superficial to the facial nerves. This degree of dissection is warranted in patients with more severe jowling. After redraping the SMAS layer, the excess SMAS is excised. The SMAS is then resuspended using a 3-0 Ethibond suture.

See the image below of a biplanar face lift surgery in progress.

Intraoperative photograph of biplanar face lift wi Intraoperative photograph of biplanar face lift with skin flap and extended SMAS flap elevated.

The first suspension vector runs from the angle of the mandible and sternocleidomastoid in the direction of the mastoid, and the second tightens the periparotid SMAS upward toward the tragus. The overall pull is superior and partially posterior.

A submental incision can be made to plicate the medial ends of the platysma if vertical banding is present in the neck. When combined with lateral platysmal tightening, a corset is created and submental contour is further improved.

A closed suction drain is used to decrease the risk of hematoma formation. The postauricular flap and temporal region are trimmed, and the skin is reapproximated with skin staples. Otherwise, the non–hair-bearing skin is reapproximated with a 5-0 nylon sutures in an interrupted fashion, paying attention to wound end eversion. Creation of a hemostatic net has also been shown to prevent hematoma in a study of 405 patients. [10]

In a retrospective study, Rosenfield evaluated the use of a solely lateral, “low” SMAS technique in place of the midline open neck lift employed in association with SMAS rhytidectomy. Full correction of neck deformities in the study’s 198 patients was reported, with faster recovery times achieved than with traditional direct neck lifts. [11]


Postoperative Details

Postoperatively, methylprednisolone (Medrol) is prescribed, as well as high-dose vitamin C therapy (1000 mg TID) and Arnica Montana and bromelain therapy. This helps minimize bruising and swelling. Prophylactic antibiotics, usually cephalexin (Keflex), are also prescribed.



The major complications following facelift surgery include hematoma, nerve injury, and incisional problems. Complications are related to the extent of the surgery and degree of hemostasis.

Hematomas are the most common complication and occur in as many as 8.5% of cases. An expanding hematoma is a surgical emergency that requires immediate operative intervention. If unrecognized and untreated, it may result in complete loss of the newly dissected skin flaps. Smaller or delayed hematomas can be managed with serial needle aspiration and pressure dressing. These complications are minimized with careful attention to intraoperative hemostasis. Use of closed suction drains may be helpful.

The most commonly injured nerve in rhytidectomy is the greater auricular nerve. The skin flap in the area of the sternocleidomastoid muscle is adherent to the fascia in which the greater auricular nerve travels. Therefore, sharp dissection or traction can injure the nerve. Attention to detail when dissecting in this area can minimize this complication. The frontal branch of the temporal-zygomatic division of the facial nerve is the next most commonly injured nerve (2.6-4%). It is vulnerable because of its superficial location as it traverses the midportion of the zygomatic arch. A more superficial dissection in this area minimizes neural damage. Injury to the marginal nerve can occur when extensive tissue dissection is performed in the neck. If a platysmal transection is performed, the possibility of nerve injury increases. Buccal motor nerve branches can also be injured with aggressive dissection medial to the anterior border of the parotid gland.

Unattractive wide scars can result from excessive skin tension. This is avoided by careful incision placement, SMAS suspension, and redraping of the skin flap without tension. An elongated earlobe directly attached to the facial skin, known as a pixie-ear deformity, is another common complication. This is prevented by leaving a generous amount of perilobular skin on the redraped skin flap during closure.


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