The SMAS facelift – restoring facial shape in facelifting

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CHAPTER 8 The SMAS facelift – restoring facial shape in facelifting

James M. Stuzin

Introduction

The works of Skoog, Mitz and Peyronie enlightened plastic surgeons to the possibility of repositioning descended facial fat to the anatomic position of youth, providing an alternative to skin envelope tightening to enhance contour in the aging face. The recognition that sub-SMAS dissection offered a technical solution for facial rejuvenation spawned multiple anatomic studies to delineate an accurate understanding of facial soft tissue anatomy. This led to further investigations which more clearly defined both the anatomic and morphologic changes which occur in the aging face, leading to a plethora of technical approaches for facial rejuvenation. In reviewing the literature, good results can be seen utilizing what appears to be very different technical approaches. In reality, most of these seemingly different technical procedures share a common theme that contour restoration is predominantly through the re-elevation of facial fat as opposed to skin envelope tightening. While good results are possible through a variety of techniques, in my opinion, all methods have advantages, disadvantages and limitations, with the ultimate result often dependent upon underlying skeletal support and the quality of facial soft tissues for a particular patient. From my perspective, the key to consistent results in facelifting is not the particular technique utilized, but rather the preoperative aesthetic analysis and how the operative plan is individualized according to the aesthetic needs of the patient.

To consistently improve facial shape in facelifting requires the surgeon to accurately understand both facial anatomy and the anatomic changes which have occurred in aging for a particular patient, appreciate the importance of underlying skeletal support in formulating the treatment plan, and incorporating one’s aesthetic vision into a surgical destination which is appropriate for a specific patient.

History

All early facialplasty procedures were limited to skin excision and wound closure without subcutaneous undermining. Bames described subcutaneous face and neck undermining, skin redraping, and excision of excess skin. The continuous incision described by Bettman and subcutaneous undermining recommended by Bames essentially established the basic facelift procedure for the next 40 years.

Skoog described a technique of dissection of the superficial fascial layer in the face in continuity with the platysma muscle in the neck and advancement of the myofascial unit in a cephaloposterior direction. This was the beginning of the modern era in facelifting. Mitz and Peyronie used cadaver dissections to define the limits of the superficial musculoaponeurotic system (SMAS) in the face and noted that tightening of this layer would be beneficial in facialplasty. SMAS-platysma facelifting, wide skin undermining, and extensive fat removal soon gained worldwide popularity. Surgery of the tissue layers deep to the skin of the face and neck is now established as an essential part of cervical and facialplasty operations. Many surgeons have described different SMAS-platysma techniques to improve the cervicofacial area and to remedy problems not corrected by conventional facialplasty.

Furnas, in 1989, described the retaining ligaments of the midface, which led to a better understanding of anatomic areas where facial soft tissue is supported and the involvement of these ligaments in leading to the anatomic changes that occur with aging. These ligaments were further defined by others who felt that loss of the support from the retaining ligament system allowed facial fat to descend inferiorly in the face, deepening the nasolabial fold and forming facial jowls with aging. The importance and location of the retaining ligaments led to modifications in procedures involving retaining ligament release in sub-SMAS dissection, the primary goal of these procedures being to reposition descended facial fat back to the anatomic location of youth. Other surgeons, preferring subperiosteal rather than sub-SMAS dissection to reposition fat, developed procedures whose similar goal is to resuspend descended malar fat to the malar eminences using the subperiosteal plane. A combination of subperiosteal and subcutaneous lifting has also been described.

Physical evaluation – patient planning

• Skin quality and elasticity.

• Age.

• Subcutaneous fat accumulation.

• Contour change developing from attenuation of deep layer support, i.e. jowling, deep nasolabial fold; and platysma banding with cervical obliquity.

• Degree of facial deflation.

• Degree of skeletal support – malar prominence, mandibular ramus height and length of mandibular body.

• The relationship between malar convexity and submalar concavity.

Anatomic considerations

The anatomic basis that allows rhytidectomy to be performed safely is that the facial soft tissue is arranged as a series of concentric layers. This concentric arrangement allows dissection within one anatomic plane to proceed completely separate from structures lying within another anatomic plane. The layers of the face are the (1) skin; (2) subcutaneous fat; (3) SMAS (superficial facial fascia); (4) mimetic muscles; (5) parotidomasseteric fascia (deep facial fascia); and (6) plane of the facial nerve, parotid duct, buccal fat pad, and facial artery and vein.

The anatomic components of facial soft tissue anatomy, which are essential for the surgeon attempting to master sub-SMAS dissection to understand include the following:

1. Although there is variation in the thickness of the various layers from patient to patient, structures within each layer are anatomically constant. On a two-dimensional basis, the facial nerve exhibits a variety of branching patterns, but on a three-dimensional basis, the facial nerve always lies within a specific anatomic plane. This anatomic arrangement allows the surgeon to perform extensive sub-SMAS dissection safely, as long as the dissection proceeds at a level superficial to the plane of the facial nerve.

2. There is significant variability in terms of the thickness of the superficial fascial layer (SMAS). This variability of SMAS thickness is obvious from patient to patient. Also, the thickness of the SMAS will vary from one region of the face to another. Overlying the parotid gland, within the temporal region (temporoparietal fascia) and within the scalp (galea), the superficial fascia (SMAS) represents a substantial, discrete layer. As the superficial fascia is traced anteriorly in the face, overlying the masseter, buccal fat pad, and into the malar region, the SMAS tends to become thinner and less substantial. To elevate the superficial fascia in these areas requires precise dissection, so that the flap is thick enough to be useful in facial contouring.

3. The muscles of facial expression are arranged in four anatomic layers which overlap one another. The muscles that are encountered in facelifting, including the platysma, orbicularis oculi, zygomaticus major and minor, and risorius muscle, are all superficially situated mimetic muscles. This is in contrast to deeply situated mimetic muscles such as the buccinator and mentalis muscle. Most of the muscles of facial expression lie superficial to the plane of the facial nerve. Because these muscles are superficial to the plane of the facial nerve, they receive their innervation along their deep surfaces. The only muscles within the facial soft tissue architecture that lie deep to the plane of the facial nerve are the mentalis, buccinator, and levator anguli oris muscles. Because these muscles lie deep to the plane of facial nerve, they receive their innervation along their superficial surfaces.

4. The muscles of facial expression, which are situated superficially within the facial soft tissue architecture and are involved with the movement of facial skin, are invested by the superficial fascia, which lines both the superficial and deep surfaces of these muscles. Because these muscles are invested by superficial fascia, this SMAS-mimetic muscle complex forms a single anatomic and functional unit whose components work together to move facial skin during animation.

5. Deep to the SMAS-mimetic muscle complex lies the deep facial fascia. The deep facial fascia represents a continuation of the superficial layer of the deep cervical fascia cephalad into the face. Where this fascial layer is identified, it is given specific nomenclature. Overlying the parotid gland, the deep fascia is termed “parotid fascia” or “parotid capsule”; overlying the masseter muscle, it is termed “masseteric fascia”; and in the temporal region, it has been termed “deep temporal fascia.” The significance of the deep facial fascia is that all the facial nerve branches within the cheek lie deep to the deep facial fascia. Typically, these nerve branches course deep to the deep fascia until they reach the muscles of facial expression that they innervate, at which point they penetrate the deep fascia to innervate these mimetic muscles along their deep surfaces (Fig. 8.1).

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Fig. 8.1 A, Cadaver dissection after SMAS-platysma elevation within the cheek exposing the underlying parotid gland, the anterior border of parotid (marked in ink), and the parotid-masseteric fascia (held in forceps). The surgical significance of the parotid-masseteric fascia is that the facial nerve branches within the cheek are always deep to this anatomic layer. B, Cadaver dissection after elevation of the parotid-masseteric fascia exposing the underlying masseter muscle and the marginal mandibular nerve as it crosses the facial artery and vein.

From Stuzin JM, Baker TJ, Gordon HL. The relationship of the superficial and deep facial fascias: relevance to rhytidectomy and aging. Plast Reconstr Surg 1992;89:441.

In an overview of the architectural arrangement of the facial soft tissue, the essential point to grasp is that there is a superficial component of the facial soft tissue that is defined by the superficial facial fascia and includes the SMAS and those anatomic components that move facial skin (including superficially situated mimetic muscle invested by SMAS, the subcutaneous fat, and skin). This is in contrast to the deeper component of the facial soft tissue, which is defined by the deep facial fascia and those structures related to the deep fascia (including the relatively fixed structures of the face, such as the parotid gland, masseter muscle, periosteum of the facial bones, and facial nerve branches) (Fig. 8.2). As the human face ages, many of the stigmata that are typically seen in aging relate to a change in the anatomic relationship that occurs between the superficial and deep facial fascia.

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Fig. 8.2 Facial soft tissue is maintained in a normal anatomic location by a series of supporting ligaments. The zygomatic and mandibular ligaments are examples of osteocutaneous ligaments that originate from the periosteum and insert directly into the dermis. The masseteric cutaneous and parotid cutaneous ligaments are formed as a coalescence between the superficial and deep facial fascias. Rather than originating from periosteum, these ligaments originate from relatively fixed facial structures such as the parotid gland and the anterior border of the masseter muscle. Attenuation of support from the retaining ligaments is responsible for many of the stigmata seen in the aging face.

From Stuzin JM, Baker TJ, Gordon HL. The relationship of the superficial and deep facial fascias: relevance to rhytidectomy and aging. Plast Reconstr Surg 1992;89:441.

Extended SMAS technique

Except perhaps in the younger facelift patient, most individuals undergoing rhytidectomy will benefit from tightening of the superficial fascial layer. Restoration of support to the underlying deeper facial soft tissues has become an integral part of the rejuvenation of the aging face. If the SMAS is thin and tenuous, plication of this layer is a useful alternative to formal SMAS elevation. Nonetheless, in my opinion, better contouring and longer lasting results are obtained following a formal dissection of the superficial fascia.

In skin flap dissection, it is important to develop uniform skin flaps during the subcutaneous undermining, with care to leave some fat intact along the superficial surface of the SMAS. If the skin flaps are dissected such that no fat is left along the superficial surface of the SMAS, then the SMAS becomes more difficult to raise, appearing thin, tenuous and prone to tearing. Much of the contouring that I obtain in my facelift has to do with elevation and fixation of the SMAS layer. The more substantial the SMAS flap, often the better long-term results that can be obtained in terms of facial contouring. Transillumination when performing subcutaneous dissection is a useful technique in allowing precise skin flap elevation.

I usually carry the subcutaneous skin flap dissection well into the malar region and usually the skin overlying the lateral two-thirds of the zygomatic eminence is undermined. I prefer to stop the skin undermining several centimeters lateral to the nasolabial fold rather than undermining the skin to this facial landmark. This is to limit the dissection of the skin flap in the medial aspect of the cheek, subsequently preserving the attachments from the SMAS to facial skin. The preservation of these attachments, followed by adequate undermining of the superficial facial fascia (SMAS), will allow the surgeon to re-elevate facial skin through SMAS rotation rather than to redrape the superficial fascia completely independent of skin flap redraping. The ability to re-elevate and resuspend facial skin through SMAS rotation, in my opinion, produces a more pleasing aesthetic result in most patients, and preserves some of the peripheral vascularity to the facial skin flap.

SMAS elevation

The dissection of the superficial fascia allows the surgeon to re-elevate jowl and descended malar fat back upward into the face toward their previous normal anatomic location. In patients with prominent nasolabial folds, and significant malar pad descent, it has been my feeling that the SMAS dissection should extend into the malar region in an effort to re-elevate the malar fat pad back upward overlying the zygomatic eminence. An added benefit of performing a more extensive anterior dissection of the SMAS is that it frees this layer from the restraint of both the zygomatic and masseteric ligaments, and this anterior release provides for a more complete elevation of the facial fat below the oral commissure and along the anterior portion of the jowl.

The incisions for extended SMAS dissection begin approximately 1 cm inferior to the zygomatic arch to ensure frontal branch preservation (Fig. 8.3). This horizontal incision is continued several centimeters forward to the region where the zygomatic arch joins the body of the zygoma. At this point, the malar extension of the SMAS dissection begins with the incision angling superiorly over the malar eminence toward the lateral canthus for a distance of 3 to 4 cm. On reaching the edge of the subcutaneous skin flap in the region of the lateral orbit, the incision is carried inferiorly at a 90 degree angle toward the superior aspect of the nasolabial fold. A vertical incision is designed along the preauricular region, extending along the posterior border of the platysma to a point 5 to 6 cm below the mandibular border. In essence, the malar extension of the SMAS dissection simply represents an extension of a standard SMAS dissection into the malar region in an attempt to obtain a more complete form of deep layer support.

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Fig. 8.3 In patients with prominent nasolabial folds, I perform what I term an extended SMAS dissection. By this, I mean I extend the SMAS dissection into the malar region in an attempt to re-elevate ptotic malar fat back upward over the zygomatic prominence. The incisions begin at the junction where the zygomatic arch joins the body of the zygoma. From this point, the incision in the SMAS is angled superiorly toward the lateral canthus and along the lateral orbital rim. The incision in the SMAS is then carried medially and inferiorly toward the peripheral extent of skin flap undermining, angling toward the uppermost portion of the nasolabial fold (the amount of subcutaneous undermining is shaded in pink, whereas the amount of SMAS undermining is shaded in yellow).

From Baker TJ, Gordon HL, Stuzin JM. Surgical rejuvenation of the face, 2nd edn. St. Louis: Mosby-Year Book, 1996, pp. 254–255.

The SMAS in the malar region is then elevated in continuity with the SMAS of the cheek. When elevating this flap, the fibers of the orbicularis oculi, as well as the zygomaticus major and minor, are usually evident and the flap is elevated directly along the superficial surface of these muscles. It is important to carry the dissection directly external to these muscle fibers, where a natural plane exists, remembering that the facial nerve branches lie deep to these muscular bellies. The malar SMAS is then elevated until the flap is freed from the underlying zygomatic prominence. Freeing of the SMAS completely from the zygomatic attachments is an important technical point in obtaining the mobility necessary to reposition the malar soft tissue superiorly. To obtain this mobility usually also requires a division of the upper fibers of the masseteric cutaneous ligaments, which will expose the underlying body of the buccal fat pad. The cheek portion of the SMAS dissection is performed beginning directly overlying the parotid gland and then extending this dissection anterior to the parotid utilizing a combination of sharp and blunt dissection toward the anterior border of the masseter (Fig. 8.4).

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Fig. 8.4 A&B, The malar-SMAS dissection is then performed in continuity with the cheek-SMAS dissection. Dissecting in the malar region carries the dissection directly along the superficial surface of the zygomaticus major and usually exposes the lateral aspects of the zygomaticus minor as well. To obtain adequate mobility in terms of SMAS dissection, it is necessary to elevate the malar portion of the dissection completely from the zygomatic eminence and free it from the zygomatic ligaments. To obtain mobility in terms of SMAS movement affecting the jowl contour, the uppermost portions of the masseteric cutaneous ligament commonly are divided, especially where they merge with the zygomatic ligaments of the malar area. If these fibers are not divided, they will restrict the upward redraping of jowl fat. This diagram and intraoperative photograph illustrate the typical degree of mobilization performed in the extended SMAS dissection.

From Baker TJ, Gordon HL, Stuzin JM. Surgical rejuvenation of the face, 2nd edn. St. Louis: Mosby-Year Book, 1996, pp. 254–255.

In most patients, following extended SMAS dissection of the cheek and malar regions, mobility of the soft tissues lying lateral to the nasolabial fold remains restricted unless the dissection is carried more medially. This restriction in movement results from the undivided retaining ligaments which originate medial to the zygomaticus minor. To improve mobility, I commonly continue malar pad elevation medially in an area where we have not subcutaneously undermined the skin. This dissection is carried directly in the plane between the malar fat and the superficial surface of the elevators of the upper lip. It is usually quite easy to delineate this level of dissection after the malar SMAS elevation is complete, and the superficial surface of the elevators of the upper lip is visualized. The scissors are then inserted directly superficial to the elevators of the upper lip, and blunt dissection is quickly performed by pushing the scissors in a series of passes bluntly toward the nasolabial fold. We find that when we insert the scissors in the proper plane, the dissection quickly glides through the malar soft tissues and we usually will feel a “snap” as we dissect through the remaining retaining ligaments. Once these structures are divided, one notes greater mobility when traction is applied to the malar portion of the SMAS flap, translating into greater movement along the uppermost portion of the nasolabial fold (Fig. 8.5).

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Fig. 8.5 It is commonly necessary to extend the malar SMAS dissection more peripherally than the subcutaneous dissection to obtain adequate flap mobility of the soft tissues lateral to the nasolabial fold. This portion of the dissection is easily performed by simply inserting the scissors in the plane between the superficial surface of the elevators of the upper lip and the overlying subcutaneous fat. Once the scissors are inserted in the proper plane, the surgeon bluntly dissects in a series of passes past the nasolabial fold (area marked in green). As long as the scissors remain superficial to the elevators of the upper lip, motor nerve injury will be prevented. Two or three passes are usually required to obtain adequate flap mobility.

From Baker TJ, Gordon HL, Stuzin JM. Surgical rejuvenation of the face, 2nd edn. St. Louis: Mosby-Year Book, 1996, p. 257.

Repositioning and closure of the SMAS is then performed. The malar SMAS flap is advanced superiolaterally over the zygomatic prominence in a direction perpendicular to the nasolabial fold, and usually paralleling the zygomaticus major muscle. After superior and lateral advancement, if a malar augmentation is not planned, the excess tissue can be excised and the flap securely fixated to the zygomatic periosteum with interrupted sutures. In many patients, I incorporate Vicryl mesh (an absorbable mesh) into the SMAS fixation to improve the tensile strength of SMAS closure (Figs 8.6, 8.7).

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Fig. 8.6 The vectors of redraping of the extended SMAS flap are determined according to the preoperative evaluation of the patient and are generally more cephalad than skin flap redraping.

From Baker TJ, Gordon HL, Stuzin JM. Surgical rejuvenation of the face, 2nd edn. St. Louis: Mosby-Year Book, 1996, p. 259.

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Fig. 8.7 Diagram illustrating how the excess SMAS, rather than being excised, is rolled onto itself (forming a double layer of SMAS thickness). Once the roll has been formed, it is fixated to the periosteum of the zygomatic buttress using permanent sutures. It is important to obtain a secure intraoperative fixation, and emphasize that fixation is as important as adequate SMAS mobilization. A small piece of Vicryl mesh is typically incorporated into the roll of the SMAS to improve its tensile strength.

From Baker TJ, Gordon HL, Stuzin JM. Surgical rejuvenation of the face, 2nd edn. St. Louis: Mosby-Year Book, 1996, p. 263.

If significant platysma banding is present, a platysmaplasty is performed through a submental incision. I typically approximate the medial edges of the platysma extending from the mentum caudally toward the base of the neck, followed by a transverse platysma myotomy performed low in the neck to alleviate tension along the platysma closure (Figs 8.8–8.12).

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Fig. 8.8 After edge-to-edge approximation of the platysma from the mentum to the cricoid cartilage, some form of muscle release is performed. This usually consists of a horizontal cut extending from the midline to the anterior border of the sternocleidomastoid muscle. The key to platysma transection is to perform it low in the neck.

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Fig. 8.9 A, Preoperative appearance of a 59-year-old male following a 90 pound weight loss from a gastric bypass procedure. Notice the significant areas of facial deflation along the infraorbital rim, lateral orbital rim and malar region. Also notice the radial expansion of skin and fat lateral to the nasolabial fold, most marked on the right side. Not only does malar fat descend, but attenuation of the retinacular connections among skin, fat and deep facial fascia lateral to the nasolabial line allows prolapse of soft tissue, which accentuates nasolabial prominence. B, Postoperatively, the areas of deflation along the infraorbital rim, lateral orbital rim, and malar region are improved as facial fat has been repositioned into these regions. The nasolabial folds are somewhat improved after malar pad repositioning, but correction is incomplete, especially on the right. Malar pad elevation helps to flatten the prominent nasolabial fold, but does little to correct radial expansion, with the skin lateral to the nasolabial line remaining prolapsed from its attachments to the facial skeleton.

From Stuzin JM. Restoring facial shape in facelifting: The role of skeletal support in facial analysis and midface soft-tissue repositioning. Plast Reconstr Surg 2007;119:362–376.

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Fig. 8.10 A&B, Long, thin faces often benefit from an enhancement of malar volume. SMAS dissection and facial fat repositioning carried anteriorly over the zygomatic eminence allows the surgeon to restore malar volume, thereby increasing bizygomatic diameter. When malar volume is enhanced, the face appears wider, detracting from the relatively excessive facial length.

From Stuzin JM. Restoring facial shape in facelifting: The role of skeletal support in facial analysis and midface soft-tissue repositioning. Plast Reconstr Surg 2007;119:362–376.

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Fig. 8.11 A, Preoperative appearance. Note that facial shape is oval, secondary to malar deflation, associated with an increase in submalar fullness. B, Postoperatively, following malar pad elevation, malar volume is enhanced in association with a restoration of submalar concavity, producing a more angular appearance to facial shape.

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Fig. 8.12 A, Preoperatively, this patient shows a similar blunting of the relationship between the malar and submalar regions. B, Postoperative appearance. Enhancing malar volume (and bizygomatic diameter) and restoring the concavity within the submalar region make the face appear more angular, as well as vertically shorter.

Postoperative care

The patient is provided with specific instructions about postoperative care. Some surgeons provide the patient with a printed list, whereas others prefer to give the instructions verbally.

If the patient is healing well at the end of a week or 10 days, return is advised in 2 to 3 weeks for a routine postoperative visit and again in 6 weeks. The patient is instructed to return or call at any time if there are any questions about the postoperative course.

During the first week the patient is allowed to walk and is encouraged to be up and about as much as is reasonably possible. Strenuous physical activities such as tennis, water-skiing, and golf are not permitted for 5 or 6 weeks. A good basic rule is: “If it hurts, don’t do it.”

The following postoperative recommendations have proven helpful for most patients:

• Pressure dressings are not used. A light facelift dressing is placed for the first 24 hours.

• The head of the bed is elevated at all times, but flexion of the patient’s neck is avoided because this may compromise circulation to the cervical flap.

• Appropriate pain and sleep medications are given; strong narcotics are rarely required.

• The patient may go to the bathroom with assistance on the first postoperative day and as desired thereafter.

• The first dressing is changed after 24 hours. At this time, the wounds are inspected and no further dressing is utilized.

• Preauricular sutures are removed on the fifth or sixth postoperative day.

• All sutures are removed by the tenth postoperative day.

• Antibiotics are routinely used preoperatively and for 5 days postoperatively. My current preference is Levaquin, 500 mg once daily, begun the night prior to surgery.

• If crusty or oozing, wounds are cleaned with hydrogen peroxide and coated with a topical antibiotic ointment.

Complications

No surgical procedure exists without complications. The surgeon must be able to recognize and deal with these problems. The most common complications after rhytidectomy are:

• Hematoma (70% of all rhytidectomy complications).

• Postoperative edema.

• Ecchymosis.

• Nerve injury.

• Unacceptable scarring (hypertrophic).

• Skin slough.

• Seromas.

• Contour irregularities.

• Infection.

• Patient dissatisfaction.

Pearls & pitfalls

Pearls

• Improving technical control through contouring the superficial facial fascia and platysma provides for a more consistent, aesthetically pleasing result which is natural in appearance.

• Patient selection is probably the most critical factor when determining the success of a proposed aesthetic procedure.

• Although aging represents a complex process, many of the stigmata developing in the aging face involve a change in the relationship between the superficial and deep facial fascia, with the superficial unit of the facial soft tissue descending inferiorly in relation to the fixed deeper structures of the face.

• The prime advantage of performing skin undermining separately from SMAS dissection is that it allows these two layers to be redraped along vectors which are independent of one another.

• The importance of incision quality cannot be overemphasized in diminishing the stigmata that the patient has undergone a surgical procedure.

Pitfalls

• Imprecise subcutaneous undermining of the skin flap can lead to a paucity of fat being left along the superficial surface of the SMAS, making it difficult or impossible to raise the SMAS as a discrete anatomic layer, limiting its usefulness in facial contouring.

• Not extending the release of the SMAS anterior to the adherence of the retaining ligaments limits the movement of this layer, thereby limiting surgical control in terms of restoring facial shape.

• Vertical skin tension to tighten the face often produces an unnatural surgical appearance to the postoperative result and can be avoided by utilizing the superficial fascia to vertically reposition facial fat.

• Imprecise incision design and skin flap inset can lead to noticeable scars, hairline shifts, tragal and earlobe distortion. Limiting skin tension by utilizing the SMAS to restore facial shape provides the surgeon with greater control in terms of scar perceptibility.

• Attempting to improve cervical contour through lateral platysma tension and closed suction lipoplasty of the neck provides less consistent results than approaching platysmaplasty anteriorly through a submental incision.

Summary of steps for extended SMAS procedure

1. Tragal margin incision design which respects the aesthetic units of the tragus and preserves the tragal insisura.

2. The use of transillumination to allow precise skin flap undermining which preserves the fat along the superficial surface of the SMAS provides greater consistency in SMAS flap elevation.

3. Limiting subcutaneous undermining over the buccal recess and buccinator allows this region of the cheek to be repositioned through SMAS rotation producing greater control in terms of submalar contour and jowl correction.

4. The incision of the extended SMAS dissection parallels the zygomatic arch and then extends superiorly over the malar eminence in the area where the arch joins the body of the zygoma.

5. Releasing the SMAS from the restraints of the retaining ligaments until the SMAS moves freely requires the surgeon to carry the dissection into the mobile region of the SMAS which lies anterior to the retaining ligaments over the malar eminence and parotid.

6. Vectoring the SMAS should be patient-specific and should be determined preoperatively with the patient in an upright position. Variation in vectors between the right and left side of the face are common.

7. Secure fixation of the SMAS, often incorporating Vicryl mesh into the closure improves consistency in shaping and postoperative results.

8. Approaching platysmaplasty through a submental incision and suturing the platysma from the mentum to the base of the neck provides greater control in cervical contouring.

9. Meticulous hemostasis leads to a low hematoma rate and more rapid postoperative recovery.

10. Placement of drains along the base of the neck prior to closure promotes rapid postoperative recovery.

11. Precise skin flap inset and closure with minimal tension, especially along the tragus and earlobe leads to control of scar perceptibility.

Further reading

Baker TJ, Gordon HL, Stuzin JM. Surgical rejuvenation of the face, 2nd edn. St. Louis: Mosby; 1996.

Bames H. Truth and fallacies of face peeling and facelifting. Plast Reconstr Surg. 1927;126:86.

Barton FE, Jr. Rhytidectomy and the nasolabial fold. Plast Reconstr Surg. 1992;90:601.

Connell BF. Neck contour deformities: The art, engineering, anatomic diagnosis, architectural planning, and aesthetics of surgical correction. Clin Plast Surg. 1987;14:683.

Feldman JJ. Corset platysmaplasty. Plast Reconstr Surg. 1990;85:333.

Furnas D. The retaining ligaments of the cheek. Plast Reconstr Surg. 1989;83:11.

Mitz V, Peyronie M. The superficial musculoaponeurotic system (SMAS) in the parotid and cheek area. Plast Reconstr Surg. 1976;58:80.

Owsley JQ, Jr. Lifting the malar fat pad for correction of prominent nasolabial folds. Plast Reconstr Surg. 1993;91:463.

Skoog T. Plastic surgery – New methods and refinements. Philadelphia: W.B. Saunders; 1974.

Stuzin JM. Restoring facial shape in facelifting: The role of skeletal support in facial analysis and midface soft-tissue repositioning. Plast Reconstr Surg. 2007;119:362.

Stuzin JM, Baker TJ, Baker TM. Refinements in facelifting: Enhanced facial contour using Vicryl mesh incorporated into SMAS fixation. Plast Reconstr Surg. 2000;105:290.

Stuzin JM, Baker TJ, Gordon HL, Baker TM. Extended SMAS dissection as an approach to midface rejuvenation. Clin Plast Surg. 1995;22:295–311. –

Stuzin JM, Baker TJ, Gordon HL. The relationship of the superficial and deep facial fascias: Relevance to rhytidectomy and aging. Plast Reconstr Surg. 1992;89:441.

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