History

The High SMAS technique was developed in the 1980s as a modification of the procedure described by Tord Skoog in 1974.¹ Anatomic studies^2,3 have documented the benefit of leaving the skin and subcutaneous mass attached to the SMAS in facial rejuvenation.

The initial challenge was to do so, yet still mobilize the cheek mass adequately. The second goal in designing this procedure was to lift the entire malar and mandibular subcutaneous cheek mass, as a single unit suspended by the SMAS.⁴ No portion of this repositioning technique was to place the skin on any form of greater than normal tension.

Physical evaluation

Anatomy

We view the cheek as having two components: the lower two-thirds being the subcutaneous cheek mass; and the upper one-third corresponding to the lower eyelid with its ptotic periorbital structures. Lower eyelid suspension is a necessary adjunct to high SMAS cheek suspension because the two areas overlap.

The sub-SMAS dissection at the level of the zygomatic arch and higher should be performed bluntly. This is safe because the frontal branch of the facial nerve runs deep to the SMAS over the periosteum of the zygomatic arch. Sharp dissection to the anterior border of the parotid is safe. Beyond the anterior border, the dissection should be performed bluntly to avoid the buccal branches of the facial nerve. The plane of dissection as one progresses centrally should stay superficial to the zygomaticus major muscle to avoid peripheral facial nerve branches.

Technical steps

Begin the dissection by elevating the skin flap in the preauricular area about 4 to 5 cm. Elevate only the skin that you anticipate removing. Perform subcutaneous dissection above the zygomatic arch in the lateral orbital area to release the cutaneous attachments of the crow’s feet and to facilitate a smooth redraping of the temporal skin. This maneuver also exposes the superficial side of the upper SMAS that will be divided later (Fig. 11.1).

Fig. 11.1 Extent of subcutaneous dissection.

Fritz E. Barton Jr., The ‘high SMAS’ face lift technique. Aesthetic Surgery 2002;22(5):481–486, with permission of Elsevier.

From the mastoid, carry subcutaneous dissection below the mandible to join the anterior neck dissection, if present. In the neck, the skin and platysma are managed as separate layers because more skin than platysmal advancement is desired. A separate submental approach is added when defatting or when midline platysmal plication is indicated (Fig. 11.2).

Fig. 11.2 Strong medial tension above the hyoid; lax below the hyoid.

Fritz E. Barton Jr., The ‘high SMAS’ face lift technique, Aesthetic Surgery 2002;22(5):481–486, with permission of Elsevier.

Begin dissecting the SMAS in the cheek just anterior to the tragus leaving a cuff for later suturing. Maintain the upper lateral corner of the SMAS at the root of the helix to serve as a point of later fixation. Proper SMAS dissection depth can be safely established here because the facial nerve is well protected by the substance of the parotid gland. Anatomically, the SMAS is fused to the parotid capsule.

From a surgical standpoint, establish the plane by delaminating the parotid capsule until only a thin layer of fascia remains over the gland (Fig. 11.3). Once the SMAS dissection is established, carry the dissection forward to the anterior border of the parotid. It is at this point that the facial nerve branches exit the parotid, requiring that you change dissection from sharp to blunt. Vertical spreading will release the remaining restricting fibers, the so-called masseteric cutaneous ligaments, exposing the translucent masseteric fascia that covers the facial nerve branches. It is important to visually check for the presence of this filmy fascia over the masseter muscle to confirm that the dissection in the buccal area is superficial to the facial nerve branches.

Fig. 11.3 Transition of the SMAS dissection plane.

Fritz E. Barton Jr., The ‘high SMAS’ face lift technique. Aesthetic Surgery 2002;22(5):481–486, with permission of Elsevier.

Now carry the dissection down the anterior surface of the sternocleidomastoid muscle for division of the cervical fascia and lower platysma with a 3-cm anteriorly oriented turn (towards the hyoid) to make a short “hockey stick” horizontal release and allow upward movement of the SMAS and cheek. This maneuver is performed carefully under direct visualization of the subplatysmal structures due to the proximity to the marginal mandibular branch of the facial nerve. The lateral border of the platysma may adhere to the tail of the parotid capsule, placing the proximal portion of the marginal mandibular facial nerve branch at risk if a lateral approach is used. The safest way to traverse this area is from the inside out. By following the already established sub-SMAS plane in the cheek, you can divide the platysma from its undersurface, carefully avoiding inadvertent injury to the marginal branch of the facial nerve.

At this point in the procedure the SMAS will redrape the jowl and mandibular areas quite well; however, upper cheek motion is restricted by deep attachments over the zygoma. Surgical instinct guides one to merely continue the buccal dissection from known to unknown in an upward direction over the area of the retaining ligaments. However, because the SMAS serves as the investing fascia encircling the zygomaticus major muscle, this approach lends to the muscle’s undersurface. Such a route endangers the motor innervation as the nerves here sit deep to the mimetic muscles.

To avoid nerve injury, start the upper SMAS release by scissor-spread elevating the preauricular SMAS up to and over the upper border of the zygomatic arch. Contrary to most anatomic descriptions, the SMAS does not fuse directly to the arch, but rather passes over it to fuse with the temporoparietal fascia above. The frontal branch of the facial nerve runs deep to the path of this dissection, just superficial to the periosteum, and safely beneath harm’s way.

Because this technique emphasizes a high vector pull in the cheek, it is critical to preserve the upper lateral corner of the SMAS anterior to the helix for later fixation. Carry the release along the upper border of the zygomatic arch to the lateral orbit. Avoid risk to the frontal branch of the facial nerve by dividing only the previously elevated portion of the SMAS. With this in mind, avoid tenting-up the deep fascia over the arch when raising the elevated SMAS prior to its high division.

Release the attachments of the SMAS investments of the zygomaticus major muscle. The lateral orbicularis muscle serves as a guide to the proper depth of the zygomaticus muscle. Starting from the zygomaticus origin, dissect from deep to the SMAS, up over the lateral border of the zygomaticus muscle, breaking through the investing fascia to enter the subcutaneous plane. Carry the dissection forward to, or beyond the nasolabial fold into the upper lip as needed. The extent of anterior dissection is determined preoperatively by the depth of the nasolabial fold.

Once the investing fascia has been released, the dissection has transitioned to the subcutaneous plane superficial to the mimetic muscles. Here, the entire subcutaneous malar and mandibular mass will move freely as a single unit (Fig. 11.4). By preserving the high lateral SMAS, the vector of pull can be delivered quite high over the zygomatic prominence.

Fig. 11.4 SMAS suspends the cheek mass, orbicularis suspension corrects the lower lid.

Fritz E. Barton Jr., The “high SMAS” face lift technique. Aesthetic Surgery 2002;22(5):481–486, with permission of Elsevier.

Suspend the cheek, primarily in a vertical direction, taking care to balance the vector to avoid lower eyelid distortion. Suture the SMAS flap to the temporalis muscle fascia to achieve a firm high anchor point (Fig. 11.5) and set the lifting tension. Trim the horizontally redundant SMAS in a vertical direction to oppose the cuff originally left undissected down to the level of the earlobe. Now, rotate the extension retroauricularly and place a second fixation point onto the SMAS posteriorly to the mastoid fascia. Take care to place the line of traction in the platysma just below the mandibular border. Then close the SMAS around the anterior auricular cuff to provide a broad, secure closure and to avoid the vulnerability of having only two points of fixation carrying the entire weight of the cheek.

Fig. 11.5 Cheek mass suspended.

Fritz E. Barton Jr., The “high SMAS” face lift technique. Aesthetic Surgery 2002;22(5):481–486, with permission of Elsevier.

With the SMAS closed there is no tension on the skin closure. Trim redundant skin and inset it around the ear making sure to preserve the hairline and to avoid skin traction lines. This completes the face and cheek portion of the procedure.

With the cheek mass securely suspended, you can then lift the ptotic orbicularis through the a lateral upper and lower blepharoplasty incision (Fig. 11.6). You need not attempt to lift the malar fat pad via the eyelid, because the malar portion of the cheek mass has been suspended as part of the high SMAS procedure. The power of this malar lift is evidenced by bunching of the orbicularis on the lower lids. The cheek suspension afforded by the high SMAS technique adds additional support to the lower lid orbicularis suspension, thus removing cheek weight as a cause of postoperative scleral show.

Fig. 11.6 Orbicularis flap suspended through a subciliary incision.

Fritz E. Barton Jr., The “high SMAS” face lift technique. Aesthetic Surgery 2002;22(5):481–486, with permission of Elsevier.

Final skin closure of all areas is achieved without tension, because all support is provided by the SMAS connection to the subcutaneous fatty mass rather than by the dermis. The skin is never placed under greater than normal tension.

See Fig. 11.7 for results of this procedure.

Fig. 11.7 A–F, Left column preoperative; Right column postoperative views of patient status post-endoscopic browlift, bilateral upper and lower blepharoplasty, high SMAS rhytidectomy, submental suction lipectomy, perioral and glabellar dermabrasion.

Fritz E. Barton Jr., The “high SMAS” face lift technique. Aesthetic Surgery 2002;22(5):481–486, with permission of Elsevier.

Postoperative care

Postoperatively the patient is recommended to stay overnight with a head dressing that leaves the neck open for direct inspection. Drains are placed into the neck exiting the retroauricular scalp and removed the following morning.

The following 4–6 weeks, patients are recommended to restrict their salt and limit their liquid intake to minimize edema. Otherwise, a typical postoperative rhytidectomy program should be followed.

Complications