The Superficial Musculoaponeurotic System: Does It Really Exist as an Anatomical Entity?

BACKGROUND

The exact anatomical entity behind the term superficial musculoaponeurotic system (SMAS) remains poorly understood. The different interpretations of the term SMAS by anatomists, surgeons, and histologists have caused confusion. This article aims to provide clarity regarding this term and the relevant anatomy.

METHODS

A literature review was conducted to uncover the variety of descriptions of the term SMAS. A feasibility study, followed by a conclusive series of standardized layered dissections complemented by histologic analysis and sheet plastination, was performed on 50 cadaver heads (16 embalmed and 34 fresh; mean age, 75 years).

RESULTS

Most literature considers the SMAS as layer 3, that is, a musculoaponeurotic layer that separates the subcutaneous fat of the superficial fascia from the deep fat of the deep fascia. The authors' dissections, histologic analysis, and sheet plastination demonstrated that layer 3 is present only where there are flat mimetic muscles and platysma-auricular fascia over the posterior part of the parotid gland as the evolutionary remnant of the platysma, but not between the flat mimetic muscles. Here, the subcutaneous fat is in direct contact with the deep fat without the interposition of a musculoaponeurotic layer 3.

CONCLUSIONS

Because of the absence of a distinct and complete layer 3 connecting the flat mimetic muscles, the authors conclude that the SMAS as originally described does not exist as a specific anatomical entity. In retrospect, the surgically created compound layered flap composed of a variable thickness of subcutaneous fat, mimetic muscles (eg, platysma, orbicularis oculi), and a thin layer of deep fascia is what is known as the "SMAS."

Progressive Contouring of the Platysma With Barbed Sutures

BACKGROUND

As the prevalence of neck lift surgeries increases, the field is continually enriched by evolving techniques for enhancing neck aesthetics. While many recent publications focus on deep neck procedures, it is essential not to overlook the significance of platysmal contouring as an integral aspect of neck rejuvenation surgery. Accordingly, we would like to elucidate our unique approach to contouring the platysma.

OBJECTIVES

This study was designed to assess the efficacy of the progressive contouring concept, a technique in which the neck is reshaped with barbed sutures synergistically with other treatment strategies.

METHODS

Our study encompassed 337 patients who received neck rejuvenation treatment with the progressive contouring technique from 2014 to 2021. We conducted a retrospective review to evaluate the change in cervicomental angle (CMA) with Mirror software during the preoperative and postoperative stages.

RESULTS

The study sample predominantly comprised females (304 out of 337), with a median age of 61 years (24-88). Most patients (95%) underwent deep cervicoplasty, with a surgical net applied in all cases for skin adaptation. After a median follow-up of 14 months, significant improvements were observed in CMA values (reduced from 149.8° to 106.7°). This demonstrated statistically significant differences when comparing preoperative and postoperative outcomes.

CONCLUSIONS

Progressive shaping of the neck with barbed sutures is an effective technique in neck rejuvenation. It utilizes multipoint and multivector plication, particularly when integrated with other adjunctive surgical maneuvers.

LEVEL OF EVIDENCE: 3

Clinical Practice Patterns in Facelift Surgery: A 15-Year Review of Continuous Certification Tracer Data from the American Board of Plastic Surgery

BACKGROUND

This study evaluates change in practice patterns in facelift surgery based on a 15-year review of tracer data collected by the American Board of Plastic Surgery as part of the Continuous Certification process.

METHODS

Tracer data for facelift was reviewed from 2006 to 2021. The 15-year collection period was divided into an "early cohort (EC)" from 2006 to 2014 and a "recent cohort (RC)" from 2015 to 2021.

RESULTS

Of 3400 facelifts (1710 EC/1690 RC) performed, 18% were done in hospital and 76% were done in an accredited office facility. Ninety one percent of patients were female with an average age of 61 years. There was an increase in the number of secondary facelifts (4% EC vs 18% RC; p < 0.001) and an increased number of patients concerned about volume loss/deflation (25% EC vs 37% RC; p < 0.001). The surgical approach to the SMAS involved plication (40%), flaps (35%), SMASectomy (22%) and MACS lift (6%). One percent of facelifts were subperiosteal and 8% skin-only. Significantly more surgeons used the lateral SMAS flap (14% EC vs 18% RC, p < 0.005), while less used an extended SMAS flap (21% vs 18%; p = 0.001) and MACS lift (10% EC vs 6% RC; p = 0.021) techniques. The concomitant use of facial fat grafting is becoming more common (15% EC vs 24% RC, p = 0.0001).

CONCLUSIONS

A 15-year review of ABPS tracer data provides an excellent venue for the objective assessment of the current status of facelift surgery, and key changes in practice patterns during that time.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

SMAS repositioning technique utilizing cog thread: Anatomical perspectives

INTRODUCTION

Face-lifting surgeries were once common among individuals over 60 years old due to skin laxity, but recent trends favor thread lifting in this age group. Understanding dynamic changes in facial anatomy during postural shifts is essential.

METHOD

Fresh cadaver studies have demonstrated the passage of threads through the superficial musculoaponeurotic system (SMAS) layer, confirming the efficacy of the technique. Proper insertion depth targeting SMAS repositioning, rather than superficial skin layers, is crucial.

RESULT

The natural movement of tissues secured by thread (N-Cog and N-Fix, N-Finders Inc., Korea) insertion results in lifting effects. However, complications may arise if threads affect deeper facial muscles, leading to discomfort. Fibrous septa play a significant role in guiding thread placement, with different densities influencing thread maneuverability and tissue response during lifting.

CONCLUSION

Procedures targeting SMAS repositioning using threads aim to maintain the new position of relocated tissues. Understanding structural variations in facial regions informs thread selection and placement. Aligning threads with tissue movement and the intended SMAS layer positioning is vital to prevent complications. Balancing thread insertion depth and tissue traction is critical for successful outcomes. Modern thread lifting techniques prioritize SMAS repositioning, enhancing lifting effects while ensuring procedure safety and efficacy.

The Mastoid Crevasse and 3-Dimensional Considerations in Deep Plane Neck Lifting

BACKGROUND

Advances in face and neck lifting involve release of tethering points along the superficial musculoaponeurotic system-platysma complex to freely manipulate the deep natural glide plane in the face and neck.

OBJECTIVES

The aim of this article was to determine a combination of deep plane techniques for addressing the face and neck and to elucidate, for the first time, a measurable endpoint for the gonial angle. Analysis of deep plane tethering and decussation zones was also undertaken.

METHODS

Extended deep plane surgery performed in 79 patients (158 hemifaces; age, 30-75 years; 95% female), over a 3-month period, was reviewed. Patients were followed for 1 year. Measurements were performed systematically during deep plane face and neck lifting.

RESULTS

Before intervention, the mean [standard deviation] gonial depth was 9.4 [3.6] mm on the left and 8.3 [2.7] mm on the right. The mean depth created below the gonial angle when measuring the traditional suspension to the anterior mastoid was 15.8 [3.3] mm on the left and 13.7 [2.5] mm on the right. The distance postoperatively when measuring the gonial depth after performing the crevasse technique was 23.2 [2.2] mm on the left and 22.5 [2.5] mm on the right. This represents a mean increase in the advancement of 7.4 mm on the left and 8.8 mm on the right (average, 8.1 mm) which was demonstrated to be statistically significant bilaterally (P < .0001).

CONCLUSIONS

The deep plane techniques described here aid manipulation of the deep plane and deep neck space, while also providing measurable endpoints and more effective modes of fixation by utilizing the mastoid crevasse. The use of techniques that release tension and allow redrape produce the most natural and well-balanced results.

LEVEL OF EVIDENCE: 4

Superior Vector Plication of the Mobile Anterior Midface: The Delta Facelift

BACKGROUND

Traditional plication techniques have been ineffective in addressing the anterior midface when compared to the sub-superficial musculoaponeurotic system (SMAS) "deep plane" approaches. However, by moving the plication much closer to the mobile medial fat tissues, a more effective and long-lasting plication can be accomplished without releasing the SMAS layer.

OBJECTIVES

The authors' "Delta facelift" approach combines a rotation vertical advancement of the midface fat with a dual-vector platysmaplasty and deep cervicoplasty as indicated for a harmoniously youthful neck.

METHODS

A retrospective chart review was performed on all patients who underwent facial rejuvenation with the Delta facelift technique between January 1, 2012, and May 30, 2021, for patient demographics, procedure details, outcomes, and complications.

RESULTS

A total of 283 patients underwent Delta facelift (273 females, 10 males). The average age was 60.8 years old. Primary facelift was performed in 229 patients, whereas 54 facelifts were secondary or further procedures. Adjunctive procedures included autologous fat grafting (93%), blepharoplasty (52%), and skin rejuvenating procedures (35%). There were 11 self-resolving neuropraxias, 6 minor hematomas, and 6 infections. Nine patients underwent repeat Delta facelift at an average of 9.3 years.

CONCLUSIONS

The Delta rotation vertical advancement of the anterior facial fat counters the descent and deflation associated with facial aging. Dual-vector platysmaplasty, with or without myotomy, effectively manages the jowl and delineates the jawline. Addition of deep cervicoplasty is recommended for patients with oblique necks or those with subplatysmal volume excess.

LEVEL OF EVIDENCE: 3

The deep cervical fascia neck lift

The main and more frequent problem in face lift is recurrence of neck bands. To improve face lift stability, a new aging analysis is proposed. The visible sign of face aging is skin excess. Superficial musculo aponeurotic system (SMAS) retraction is a much less visible sign. Nevertheless, botulinum toxin injections elongate muscles of the SMAS and rejuvenate the face. In the Face Recurve Concept, MRI studies prove the mimic muscles retraction that comes with aging. Face lift techniques include SMAS plication, traction or excision, which increases discrepancy between the envelope, the skin and the core, the SMAS. As skin excision is poorly efficient because performed posteriorly, far from the anterior skin excess located at the medial neck, the association to SMAS retraction exacerbates the gradient difference between envelop and core. This analysis shows that it is paramount to preserve the SMAS. (1) The sub-skin dissection has to be executed moving beyond the marionette fold and the paramedian neck bands; (2) no action is performed on the SMAS, only an horizontal section of the platysma at the hyoid height that will avoid platysma band recurrence. A botulinum toxin injection performed herein just after, blocks muscle regeneration; (3) the skin is pulled backward with a clear posterior transposition to the platysma. The skin at the cervico-mental angle and all along the cervico-mental crease is fixed to the deep cervical fascia, in the gap between the edges of the sectioned platysma, blocking muscle recreation. A resorbable barbed thread is used, with a first bite made at the cervico-mental angle through the deep cervical fascia then in the direction of the mastoid, with long bites through the deep cervical fascia versus short subcutaneous bites. Thanks to this strong shift, the cervico-mental crease is definitely recreated with no need of pre-auricular skin tension. Thirty-two patients have been operated with this technique on a one-year period. The results are a lot more stable and swelling is lowered down to the minimum.

Facelift: Assessment of Total Platysma Muscle Transection to Prevent the Recurrence of Platysmal Bands

INTRODUCTION

Determining which facelift technique yields the most effective long-term rejuvenation results and ensures optimal stability over time remains a significant question in cosmetic surgery: Does the most invasive surgery lead to the best long-term outcomes? This study aims to evaluate the authors' approach using total platysma muscle transection to prevent platysma band recurrence, and to provide anatomical observations supporting and justifying their procedure.

MATERIAL AND METHODS

A preliminary study in anatomical basic sciences was conducted to establish the rationale for our method. A prospective single-blind study was conducted, involving eighty patients seeking facial rejuvenation with platysmal band correction. They underwent face and neck-lift procedures with total platysma transection by the same surgeon between May 2013 and May 2016. Cosmetic outcomes were assessed using the Face and Neck-Lift Objective Photo-Numerical Assessment Scale. Scores by three blind evaluators before surgery, at 1 and 5 years postoperatively, were compared using a matched T Test (p < 0.05).

RESULTS

The preliminary anatomical study revealed a consistent anastomotic system between the cervical branch of the facial nerve and the branches of the cervical plexus. Incomplete platysma section during a facelift might contribute to platysma band recurrence. The clinical study demonstrated satisfactory outcomes, with significant overall appearance improvement (p < 0.00001) and no platysma band recurrence. Complication rate was low.

CONCLUSION

The authors' technique achieved satisfactory long-term results with minimal complications. However, due to the lengthy operating time and steep learning curve, it should be reserved for highly motivated patients.

LEVEL OF EVIDENCE II

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Temporal Facelift: A New Method for Temporal and Mid-face Lifting

Lifting the temporal and mid-face areas creates a very dynamic change in the facial appearance and different planes of dissection were described before. In this article, a new plane of dissection is described which allows the surgeon to perform a very quick and safe dissection in both the temporal and mid-face regions. Patients were operated on using the presented technique and brow lift, cantopexy, and mid-facelift were performed. The outcome of the surgery was analyzed by the authors from standardized photos before and 6 months after the surgery with measurements of the brow and lateral canthus. The plane of dissection is just over the subgaleal fascia which is actually the sub-superficial musculoaponeurotic system layer in the mid-face. This plane of dissection is easy and quick and creates a very mobile mid-face and temporal flap. Forty female patients were operated using the presented technique with a mean follow-up period of 15 months, the longest follow-up was 26 months. No major complication was encountered in these patients. In 5 patients, transient unilateral frontal branch palsy was encountered. In 1 patient, bilateral temporal area depression was observed 8 months after the surgery and treated with a fat injection under local anesthesia. One patient had alopecia in the temporal suture line which can be covered with hair. Temporal facelift is a versatile method with long-lasting results due to its important features; creating a very mobile flap for suspension dissection area, a large surface for adherence, and numerous sutures sharing the tension on the key sutures. Despite its slightly difficult early healing period, the technique should be kept in mind for the rejuvenation of the periorbital area and mid-face. Level of Evidence: Level I.

Defining the Cervical Line in Face-Lift Surgery: A Three-Dimensional Study of the Cervical and Marginal Mandibular Branches of the Facial Nerve

BACKGROUND

Continuous sub-superficial musculoaponeurotic system (SMAS) dissection in the cheek with subplatysmal dissection in the neck is an important feature of many face-lift techniques, yet the neural anatomy in this area remains unclear, and recommendations regarding continuous dissection of these adjacent areas vary widely. The purpose of this study was to define the vulnerability of the facial nerve branches in this transitional area from the face-lift surgeon's perspective and to specifically identify the location of the cervical branch penetration through the deep cervical fascia.

METHODS

Ten fresh and five preserved cadaveric facial halves were dissected under 4× loupe magnification. The skin was reflected, followed by elevation of a SMAS-platysma flap, with identification of the location of cervical branch penetration through the deep cervical fascia. The cervical and marginal mandibular branches were then dissected retrograde through the deep cervical fascia to the cervicofacial trunk to confirm identifications.

RESULTS

Cervical and marginal mandibular branch anatomy was found to be similar to that of the other facial nerve branches, all of which initially course deep to the deep fascia in their postparotid course. The emergence of the terminal branch or branches of the cervical branch through the deep cervical fascia was consistently at or distal to a line from a point 5 cm below the mandibular angle on the anterior border of the sternocleidomastoid muscle to the point where the facial vessels course over the mandibular border (cervical line).

CONCLUSIONS

Continuous dissection of the SMAS in the cheek, with subplatysmal dissection in the neck crossing over the mandibular border, is possible without jeopardizing the marginal mandibular or cervical branches if done proximal to the cervical line. This study serves as the anatomical justification for continuous SMAS-platysma dissection, and has implications for all types of SMAS flap manipulations.

Skin Anatomy and Analysis

This article provides a comprehensive review and strong reference for facial and neck anatomy. An anatomic foundation is built for the dermatologic concepts, techniques, procedures, and surgeries detailed in noninvasive skin treatments. Superficial anatomic landmarks have been established that allow for more nuanced navigation and measurement of facial features. Throughout this article, we discuss key anatomic features of the face and neck, compare dermal thickness in various regions and ethnic anatomic differences, review insertion points of retaining ligaments of the superficial musculoaponeurotic system, and detail diagnostic tools including ultrasound and optical coherence tomography analysis of the skin.

Surgical Management of Platysma Bands: A Narrative Review of Evolving Concepts and Changing Techniques for Neck Rejuvenation

INTRODUCTION

Platysmal bands are an unappealing feature of the aging face. Incomplete understanding of anatomy and physiology of platysmal bands has led to a long period of flawed or incomplete treatment. This review aims to elucidate the correct study of platysmal bands along with the most recent surgical treatments.

MATERIALS AND METHODS

To identify all articles related to the topic of surgical management of platysmal bands, an extensive search was performed on PubMed and Medline databases for all articles related to platysmal bands from 1990 to 2023. The articles were then reviewed by 2 independent reviewers, and all relevant articles were selected. The search was narrowed down to clinical trials and cohort studies.

RESULTS

6130 articles were identified, of which 21 articles matched the inclusion criteria and were selected for the study totaling 2331 patients. Different surgical procedures were mentioned. Assessment of results was mostly subjective and done by the surgeon.

CONCLUSION

Composite platysma-skin flap repositioning as opposed to wide skin undermining with or without submental incisions is being gradually accepted as a valid approach, with closed platysma myotomy and platysma denervation emerging as effective less invasive surgical modalities. Nevertheless, merits of more extensive procedures involving wide skin undermining and anterior platysma plication must not be lightly forgotten.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors   www.springer.com/00266 .

Sub-SMAS Reconstruction of Retaining Ligaments

BACKGROUND

Retaining ligaments must be fully released for effective soft-tissue mobilization during sub-superficial musculoaponeurotic system (SMAS) facelifts. Standard deep temporal fascia and lateral SMAS fixation techniques may fail earlier than anticipated, which may cause a relapse of facial aging signs. Reconstruction of retaining ligaments was previously proposed to enhance facelift fixation.

OBJECTIVES

The author sought to assess the effect of their ligament reconstruction technique on early relapse rates and complication rates.

METHODS

This study was a comparative analysis of 188 consecutive facelift cases where retaining ligaments were reconstructed employing the described techniques. A total 104 patients with standard fixation were analyzed in the control group. A novel set of criteria was established for the diagnosis of early relapse after facelift surgery based on the validated Merz scale.

RESULTS

Early relapse rate was significantly lower (0.53% vs 5.76%) in the ligament reconstruction group compared with the control group. Ligament reconstruction was associated with an increased rate of temporary nerve paralysis (8.5%).

CONCLUSIONS

Sub-SMAS reconstruction of retaining ligaments enhances facelift fixation and reduces the rate of early relapse. Increased risk of temporary neuropraxia is a reasonable trade-off.

LEVEL OF EVIDENCE: 4

Aging of the Neck Decoded: New Insights for Minimally Invasive Treatments

BACKGROUND

Many signs of aging manifest in the neck region, including platysmal bands, excess skin, horizontal neck lines and decreasing contour of the neck. While the clinical signs of an aged neck are well-known, data determining the underlying aging process are limited.

OBJECTIVE

To decode aging of the neck.

MATERIALS AND METHODS

This prospective study investigated elasticity and firmness of skin, muscle activity and skin displacement upon muscular contraction in the neck in 77 young-, middle- and old-age individuals. Objective outcome measures, including 3-dimensional imaging, cutometry and surface electromyography, were utilized for all assessments.

RESULTS

Mean firmness of skin decreased significantly from young to old individuals (0.37 ± 0.13 mm, 0.30 ± 0.12 mm and 0.26 ± 0.12 mm in young, middle and old subjects, respectively; p < 0.001). Gross elasticity decreased significantly from 75.1 ± 13.0% in young subjects, to 64.53 ± 15.7% in middle-aged subjects and 55.79 ± 13.0% in old subjects (p < 0.001). The mean y-axis skin displacement increased from 2.48 ± 4.33 mm in young subjects, to 3.11 ± 4.49 mm in middle-aged subjects and 3.61 ± 5.38 mm in old subjects (p = 0.006). The mean signal-to-noise ratio decreased significantly from 16.74 ± 5.77 µV in young subjects, to 14.41 ± 4.86 µV in middle-aged subjects and to 12.23 ± 5.99 µV in old subjects (p < 0.001).

CONCLUSION

This study provides insights into the interplay between skin elasticity, muscular activity and the reflected movement of the skin of the neck. Appreciation of these age-related changes lays the fundament for aesthetic treatments in this delicate region.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Total Neck Rejuvenation, Harnessing the Platysma in the Lower Neck and Décolletage

BACKGROUND

Efforts to rejuvenate the lower neck and décolletage have not been adequately addressed by neck lift techniques which predominantly focus on improving the cervicomental angle and correcting fullness in the submental and submandibular region. Disappointment with a lack of initial result in the lower neck and early relapse of laxity led the author (DJH) to adopt the Fogli/Labbé vertical neck lift with a fixation of the platysma muscles to Loré's fascia Fogli (Aesthet Plast Surg 32:531-541, 2008), Labbé et al. (Plast Reconstr Surg 117:2001-2007, 2006). Over the past 8 years, since the original "modified" Fogli description was published by Hodgkinson (Aesthet Plast Surg 36:28-40, 2012), the technique has evolved with a specific aim to improve the initial results of the neck lift in the lower half of the neck and have the result maintained in follow-up.

METHODS

The clinical photographs of female patients who underwent face and neck rejuvenation utilising a modified Fogli vertical platysma advancement technique were evaluated as to the improvement of the rejuvenation in the lower neck and décolletage and compared with the photographs obtained by the original pexy technique. The review was restricted to patients operated on in the prior extant three-year period and compared with the results of patients having surgery in that preceding five years prior to the review period.

RESULTS

The results of the recent technical modifications of the vertical lift by the platysma flap advancement were superior to the previous pexy technique and attributable to the advent of the surgical auricular-platysmal flap advancement. This flap, which in continuity with the distal platysma was affixed with permanent sutures to Loré's fascia after definitive release of the cervical retaining ligaments of the platysma.

CONCLUSION

The modifications of the vertical platysma fixation to Loré's fascia after mobilisation of the distal platysma by detachment of the cervical retaining ligaments utilising an advancement of the platysma led to improvement in the rejuvenation of the lower neck and décolletage when compared to the pexy technique of the original Fogli/Labbé description.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

The MICRO-Lift: A Ligaments-Based Anatomic Technique for Lower Face and Neck Rejuvenation Using Bipolar Radiofrequency

BACKGROUND

The aim of this paper is to present the results of a new technique for lower face and neck rejuvenation named the MICRO-lift (Minimally Invasive, Combined Radiofrequency, Outpatient lift). This technique is based on a bipolar radiofrequency treatment applied to specific ligamentous areas.

METHODS

Inclusion criteria were patients with skin laxity of the neck and jowls, with or without fat accumulation. Patients who presented platysma sag and alteration of subplatysmal structures were excluded from the study. The distribution of the energy was adapted to the ligament anatomy, differentiating three areas based on the energy concentration. In all patients, sex, age at surgery, type of anesthesia, radiofrequency parameters and complications were registered. In all cases, standard photographs and satisfaction interviews were conducted preoperatively and postoperatively. Satisfaction evaluation was also assessed.

RESULTS

Sixty-five patients underwent MICRO-lift technique for the lower face and neck. All patients in our series were female. There were no major complications. Minor complications included transient paralysis of the marginal mandibular (4,6%), infection of the submental incision that required incisional drainage (3,1%), and deep skin burn in the neck (1,5%). Fifty-nine patients were satisfied a year after the treatment (90,8%).

CONCLUSIONS

The MICRO-lift can produce outstanding and satisfying improvements in cervicofacial appearance. This new approach offers a predictable strategy to achieve the desired aesthetic results, making this procedure more reliable and reproducible for both novel and experienced surgeons with bipolar radiofrequency.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Asian Face Lift with the Composite Face Lift Technique

BACKGROUND

The composite face lift is becoming increasingly popular following recent advances in understanding of facial anatomy that enable safe sub-superficial musculoaponeurotic system (SMAS) dissection. This article presents the authors' technique for composite face lift in Asian patients and reviews their experience and outcome with this procedure.

METHODS

Composite face lifts were performed on 128 Asian patients between January of 2010 and June of 2020. Ninety-four were primary face lifts, and 34 were secondary or tertiary face lifts. The authors' surgical technique and adaptations for the specific requirements of Asian patients are described in detail. The mean follow-up was 26 months (range, 6 to 108 months). Fat grafting was an integral part of our procedure, with 95 percent having concomitant facial fat grafting with their face lift.

RESULTS

Patients were followed up in accordance with a standardized schedule. The majority of patients reported high satisfaction with the aesthetic outcome of the technique, with natural, long-lasting results. The face lift plane of dissection is through the facial soft-tissue spaces, which provide atraumatic sub-SMAS access with precise release of the intervening retaining ligaments for effective flap mobilization. By emphasizing tension on the composite flap with no tension on the skin closure, the scars were discrete in the great majority of patients. Complications were few, with no hematomas or skin flap necrosis. The temporary nerve injury rate was 1.5 percent, with no patient having a permanent nerve injury.

CONCLUSION

The composite face lift is an ideal technique for Asian patients, as it delivers natural, long-lasting results; a quick recovery; and high patient satisfaction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Sub-SMAS Transposition of the Buccal Fat Pad

BACKGROUND

Regardless of the technique chosen to treat the aging midface, the isolated lateral approach facelift has a limited impact on the midface volume deficit. In an effort to overcome this limitation, modern facial rejuvenation procedures incorporate an additional modality for replenishing the midface volume. Some of the author's facelift patients present with bulging buccal fat pads despite volume deficiency in the inframalar region. The author's technique is designed to utilize the buccal fat pad to replenish the inframalar volume deficit.

OBJECTIVES

The author sought to present the fat pad transposition surgical technique along with objective outcome data.

METHODS

This study was a retrospective review of nonconsecutive cases where the sub-superficial-musculo-aponeurotic-system transposition of the buccal fat pad was performed. A total of 22 patients underwent the fat pad transposition technique by the author (O.B.) between July 2013 and December 2017. Patient data were obtained from patient records, 3-dimensional models, magnetic resonance images, and standardized photography. Preoperative differences in midface volume were assessed utilizing curvilinear surface measurements on 3-dimensional models and the Allergan midface volume deficit scale on standardized photography.

RESULTS

The average midface volume deficit score significantly improved, and the average midfacial curvilinear surface measurement significantly increased after surgery. Magnetic resonance imaging confirmed a stable position of the buccal fat pad after surgery.

CONCLUSIONS

The sub-superficial-musculo-aponeurotic-system transposition of the buccal fat pad is an effective technique that can be safely employed for autologous inframalar augmentation in patients with a favorable facial morphology.

LEVEL OF EVIDENCE: 4

The Super-High SMAS Facelift Technique with Tailor Tack Plication

BACKGROUND

Super-high superficial musculoaponeurotic system (SMAS) suspension and tailor tack plication are powerful facelift tools used in cases of primary facial rhytidectomy.

TECHNIQUE

Thorough pre-operative patient screening and counseling are completed in an outpatient cosmetic surgery center. A super-high SMAS flap is developed by undermining and incising along a line extending from the tragus to lateral canthus and dissecting the SMAS sufficiently to induce movement of the lateral nose and the oral commissure with traction on the SMAS. The SMAS is suspended from the deep temporal fascia using 4-0 Mersilene sutures. Tailor tack sutures are placed strategically in the SMAS caudal to the malar bone to eliminate any residual laxity in the SMAS close to the oral commissures and the cheek area. This is repeated until the laxity of the SMAS is completely eliminated. The orbicularis muscle is conservatively suspended laterally from the deep temporal fascia, facial volume is restored with fat grafting, the neck is contoured, if necessary, and the vest-over-pants platysma overlap technique is commonly utilized. Concomitant forehead rejuvenation, blepharoplasty, and laser resurfacing are extremely common.

RESULTS

Of the 72 cases of primary rhytidectomy performed by the senior author on consecutive patients included in the study, there were 64 (89%) female and 8 (11%) male patients. The average age of the patient at the time of primary facelift was 58 years old. Fifteen out of 72 (21%) patients received one dose of desmopressin (DDAVP) injection during the surgery, and one patient received DDAVP the day after surgery to maintain hemostasis. There was no incidence of facial nerve injury. Of those 72 cases, 3 (4%) developed minor hematomas that were resolved by aspiration. There were no expanding hematomas that required surgery. Of the 26 patients whose satisfaction was documented, 24 were very satisfied. Two patients expressed their dissatisfaction with the results, and one of these patients underwent a revision operation by the senior author. The other patient was mainly not pleased with the recovery duration.

CONCLUSION

An alteration in the SMAS elevation and suspension is described with strategic submalar plication, providing a powerful technique for primary facial rhytidectomy that offers reliable and significant malar lift, orbicularis suspension, improvement in jowls, and repositioning of the oral commissure. The technical details are demonstrated through complete video segments along with many nuances that make delivery of optimal and natural outcomes possible, while maintaining the normal anatomy.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Hyo-neck lift evolution: Neck lift with fixation of the platysma to the deep cervical fascia

The aim of any neck lift obviously includes the restoration of an acute cervicomandibular angle. The hyo neck lift, first published in April 2016, did proposed a new technique of neck lift with a sub-cutaneous neck dissection and suture of the platysma to the hyoid through this sub-cutaneous approach. To enhance results and efficiency, a major change of the hyo neck lift technique is herein proposed with a vertical anterior sub-platysmal and sub-platysmal fat opening and dissection. This anterior dissection ensures a precise and efficient fixation of the platysma to the deep cervical fascia on direct visual control. This permits to create an horizontal and posterior vector of tension on both platysma and skin, which induces flattening of the submental area and consequently creates or recreates an acute cervicomandibular angle. The sub-cutaneous dissection is no more necessary at the hyoid level. In addition, the posterior border of the anterior platysmal flap is suspended to the mastoid fascia. If necessary, the submandibular gland, through this lateral approach, can be partially excised inside it's capsule, after strong bipolar coagulation. A botulinum toxin injection, realized in early post-op, will definitively stabilize the platysma to deep cervical fascia fixation. Fifteen patients underwent the new technique of neck lift with fixation of the platysma to the deep cervical fascia and suspension of the lateral platysma (Platysma Fixation Platysma Suspension: PF PS) and were evaluated at one year post-op and compared to the results obtained with the first preliminary prospective study "hyo neck lift technique" published in April 2016. As now subcutaneous dissection is limited, recovery is faster. No transient nerve damage happened because dissection planes are designed to be far from nerve branches.

CONCLUSIONS

The simplest way to obtain an acute cervicomandibular angle is to reattach the platysma to the deep cervical fascia along the platysma cords. The new neck lift with fixation of the anterior platysma to the deep cervical fascia and suspension of the lateral platysma, is faster to perform, induces a faster recovery and is safer and more efficient than the subcutaneous hyo neck lift and other described types of anterior platysma plasties.

A Simplified Method for Management of Platysmal Bands: Platysmotomy as an Office Procedure

Restoration of the esthetic neck contour is an integral component of facial rejuvenation. Characters of the aging neck include lipodystrophy, platysmal bands and jowls that extend into the neck, reducing the esthetic characters of the lower face. The authors present a new, simplified and economic method to manage platysmal bands as an office procedure under local anesthesia using a standard 18-gauge syringe needle as a cutting tool. The new technique was used on a selected group of female patients classified as non-surgical cases according to Rorich classification. Twenty-five female patients shared in this study, with a follow-up period standardized to 1 year; one patient showed up after 1.5 years with preserved esthetic outcome. One patient showed residual band managed by recutting immediately after bruising and edema resolved. The technique was proven safe regarding important neurovascular structures of the neck. Patients gave no negative comments regarding results of surgery. Kappa statistical analysis showed perfect interobserver agreement between patients and an independent assessor. The authors concluded that the studied new technique is safe, effective, and valuable for management of platysmal bands in a selected group of patients. Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Bilayered Structure of the Superficial Facial Fascia

Background

The superficial facial fascia comprises the superficial musculoaponeurotic system (SMAS) and the temporoparietal fascia (TPF) and is regarded as a continuous monolayer. However, some evidence indicates that the superficial facial fascia consists of 2 layers in specific areas.

Objectives

The authors evaluated the superficial facial fascia for bilayered regions.

Methods

Twenty fresh cadavers (40 hemifaces) were dissected to observe the superficial facial fascia. Twelve cadavers were dissected to assess tensile strengths of the superficial and deep layers of the SMAS. Specimens were obtained from 2 cadavers for histologic analysis.

Results

The SMAS and TPF were separable into superficial and deep layers, with intervening areolar tissue. The deep TPF was continuous with the deep SMAS inferiorly and the subgalea anteriorly. The superficial orbicularis oculi was invested by the superficial SMAS, whereas the deep orbicularis and the platysma were invested by the deep SMAS. Thus, 2 key structures addressed in facial rejuvenation are positioned in different surgical planes.

Conclusions

Study results support the belief that the superficial facial fascia comprises 2 layers, with the superficial orbicularis oculi and platysma invested by different layers. These findings have implications for facial rejuvenation techniques that involve management of the SMAS and TPF.

Presto lift-a facelift that preserves the retaining ligaments and SMAS tethering

Background

Producing youthful facial appearance by face-lifting often comes along with an undesired loss of patient’s individual phenotype. This may result from insufficient preservation of retaining ligaments, the “guardians of facial identify,” and from severance of the intersegmental connections of the superficial musculo-aponeurotic system (SMAS), which tether, structure, and compartmentalize facial soft tissue into defined, relevant anatomical zones.

Methods

The technique reported here preserves most retaining ligaments. They serve to fix the facial soft tissue mass in loco. With the possible exception of the zygomatic-cutaneous ligament, they are only carefully distended. The SMAS intersegmental connections and the zygomatic SMAS border are preserved to retain effective points of facial tissue fixture. Aging-associated thinning and lengthening of the lower eyelid are reduced by midfacial-submalar preparation (Aston 1996). Subplatysmal preparation and disconnection of the cranial-platysmal border permits optimal modeling of neck structure.

Results

The combination of preservation of retaining ligaments and SMAS tethering (“PRESTO facelift”) introduced here as a novel face-lifting technique conserves the individual esthetics of the patient by approaching her/his individual phenotype from decades ago. In addition, undesired outcomes of facelift surgery and common risks of facelift surgery are circumvented.

Conclusions

The PRESTO facelift technique generates optimal esthetic results that conserve a patient’s personal facial identity, besides restoring a more youthful appearance and being rapid and safe.

Total Composite Flap Facelift and the Deep-Plane Transition Zone: A Critical Consideration in SMAS-Release Midface Lifting

BACKGROUND

Recent anatomic studies suggest the superficial musculoaponeurotic system (SMAS) layer attenuates in the midface. This led the author to switch from a bilamellar high SMAS dissection to a "total composite flap" technique, preserving skin and SMAS/platysma as one layer in a critical "deep-plane transition zone" (DTZ) lateral to the zygomaticus major muscle. This allows traction on the SMAS to translate to the malar fat pad via a "cantilever bridge" effect, which is lost when skin is undermined in the DTZ.

OBJECTIVES

This paper attempts to answer the question of whether the composite flap or bilamellar technique better lifts the midface, comparing groups where the DTZ was undermined: (1) only at a sub-SMAS level; or (2) at both subcutaneous and sub-SMAS levels.

METHODS

Thirty-five patients underwent bilamellar facelifts with skin and SMAS separated in the DTZ. Midfacial elevation was measured using size-matched preoperative and 18-month (average) postoperative photographs for the 70 hemi-midfaces. The same analysis was done for 35 patients undergoing total composite flap facelift, maintaining skin and SMAS as one layer in the DTZ. The two groups were compared.

RESULTS

In the bilamellar group, the mean percentage of midfacial elevation at 18 months postoperative was 5.5% (range, 0.0%-17.8%). In the composite flap group, the percentage was 11.7% (range, 0.1%-32.3%). The difference was statistically significant.

CONCLUSIONS

Maintaining skin-SMAS attachments in the DTZ improves midface elevation during SMAS facelifting, exploiting a "cantilever bridge" effect of the skin transferring traction on the SMAS to the malar fat pad.

SMAS Fusion Zones Determine the Subfascial and Subcutaneous Anatomy of the Human Face: Fascial Spaces, Fat Compartments, and Models of Facial Aging

BACKGROUND

Fusion zones between superficial fascia and deep fascia have been recognized by surgical anatomists since 1938. Anatomical dissection performed by the author suggested that additional superficial fascia fusion zones exist.

OBJECTIVES

A study was performed to evaluate and define fusion zones between the superficial and the deep fascia.

METHODS

Dissection of fresh and minimally preserved cadavers was performed using the accepted technique for defining anatomic spaces: dye injection combined with cross-sectional anatomical dissection.

RESULTS

This study identified bilaminar membranes traveling from deep to superficial fascia at consistent locations in all specimens. These membranes exist as fusion zones between superficial and deep fascia, and are referred to as SMAS fusion zones.

CONCLUSIONS

Nerves, blood vessels and lymphatics transition between the deep and superficial fascia of the face by traveling along and within these membranes, a construct that provides stability and minimizes shear. Bilaminar subfascial membranes continue into the subcutaneous tissues as unilaminar septa on their way to skin. This three-dimensional lattice of interlocking horizontal, vertical, and oblique membranes defines the anatomic boundaries of the fascial spaces as well as the deep and superficial fat compartments of the face. This information facilitates accurate volume augmentation; helps to avoid facial nerve injury; and provides the conceptual basis for understanding jowls as a manifestation of enlargement of the buccal space that occurs with age.

Is the SMAS Flap Facelift Safe? A Comparison of Complications Between the Sub-SMAS Approach Versus the Subcutaneous Approach With or Without SMAS Plication in Aesthetic Rhytidectomy at an Academic Institution

BACKGROUND

For treating the aging face, a facelift is the surgical standard. A variety of techniques have been described. The purpose of the current study is to evaluate the safety of the sub-SMAS facelift compared to the subcutaneous facelift with or without SMAS plication.

METHODS

A retrospective chart review was conducted on all patients who underwent facelift surgery between 2003 and 2011. Patients included in the study were seeking elective improvement of facial appearance. All charts were reviewed to identify the presence of hematoma, seroma, deep venous thrombosis, skin loss, unfavorable scar, wound infection, or motor and sensory deficit following the operation. The primary outcome was overall complication rate.

RESULTS

A total of 229 facelifts were included; 143 patients underwent a subcutaneous facelift with or without SMAS plication and 86 underwent a sub-SMAS facelift. For the subcutaneous facelifts, 88% of the patients were female with a mean age of 62 years. For the sub-SMAS dissections, 88% of the patients were female with a mean age of 59 years. The overall complication rate was 29.4% (n = 42) for patients who underwent a subcutaneous facelift compared to 24.4% (n = 21) for patients with a sub-SMAS facelift (p = 0.4123). Analysis of each individual complication failed to yield any statistically significant difference between the two groups.

CONCLUSIONS

In the present study, sub-SMAS facelift complication rates were not statistically different compared to those of subcutaneous facelift with or without SMAS plication. These data suggest that sub-SMAS dissection can be performed with similar safety compared to the traditional subcutaneous facelift, with the potential additional advantage of the SMAS flap elevation.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

A Comparison Between Two Methods of Face-Lift Surgery in Nine Cadavers: SMAS (Superficial Musculo-Aponeurotic System) Versus MACS (Minimal Access Cranial Suspension)

BACKGROUND

This study aimed to compare the average amounts of facial skin and muscle lifting in two different face-lift methods, superficial musculo-aponeurotic system (SMAS) plication and minimal access cranial suspension (MACS), to evaluate the effectiveness of each method in facial excursion.

METHODS

Thirty-six face-lift surgeries were performed on nine cadavers between October and December 2010. Both SMAS and MACS surgeries were done on each side of the cadaver faces. The average amounts of skin and muscle lifting up and out in three defined anatomical landmarks were compared between the two methods, SMAS plication and MACS lift procedure.

RESULTS

Nine fresh cadavers with the mean age of 53 ± 6.7 years entered the study. Seven (77.8 %) were males and two (22.2 %) were females. The average amounts of lifting of the anatomical landmarks up and out were significantly greater in the SMAS plication method compared to the MACS lift procedure (P values <0.05), whereas facial symmetry was not significantly different between the two methods.

CONCLUSION

The overall amounts of facial skin and muscle lifting by the SMAS plication method were greater than the MACS lift procedure. However, it does not justify ignoring the benefits of the MACS lift procedure in terms of less invasiveness and quicker recovery.

NO LEVEL EVIDENCE

This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Development and Validation of a Clinical Assessment Tool for Platysmal Banding in Cervicomental Aesthetics of the Female Neck

BACKGROUND

In facial aesthetics, grading systems are useful tools for planning aesthetic procedures. One key component of rejuvenation--the anterior neck--has been relatively overlooked. In the 1980s, criteria were established for the appearance of a youthful neck. Considering the significant contribution of the anterior neck to the aesthetics of the lower face, updated and more extensive clinical evaluation tools are critical to successful execution and measurement of rejuvenation. A validated assessment scale has yet to be created for platysmal banding, one component of the anterior neck that significantly contributes to the aesthetics.

OBJECTIVES

The purpose of this study was to establish a validated platysmal banding scale for clinical application.

METHODS

Three-dimensional standardized photographs from over 100 volunteer patients of various ages and ethnicities were analyzed to develop a five-point scale for platysmal banding. The scale was validated by a group of academic and nonacademic attending plastic surgeons as well as senior level plastic surgery residents then analyzed through a two stage process to ensure both interrater and intrarater validity.

RESULTS

We measured the Intraclass Correlation Coefficients (ICC) for the interrater reliability. ICCs ranged from moderate to excellent agreement. Cronbach's alpha, which represents intrarater reliability, was also calculated for the same sample with all results being good to excellent.

CONCLUSIONS

This study established a validated scale to assess the degree of platysmal banding in the female neck. This grading system has potential application in the preprocedure planning for patients considering face and neck rejuvenation to address platysmal banding.

Are There Differences Between the Upper and Lower Parts of the Superficial Musculoaponeurotic System? A Preliminary Biomechanical Study

BACKGROUND

The superficial musculoaponeurotic system (SMAS) becomes thinner and gradually disappears from the midface. In rhytidectomy, manipulation of the SMAS occurs in the lateral area, and previous research has focused primarily on the SMAS region as a whole.

OBJECTIVES

In this preliminary study, the authors compared the viscoelasticity of the upper and lower regions of the SMAS using biomechanical techniques.

METHODS

Two adjacent projection regions of the SMAS were designated: region 1 and region 2, representing the upper and lower parts, respectively. The SMAS tissues from 8 fresh-frozen cadaver heads were cut into 64 samples before biomechanical testing, and the following variables were recorded for subsequent analysis: stress-strain curve, elastic modulus, ultimate strength, and elongation at break.

RESULTS

The stiffness of region 1 was markedly greater than that of region 2. Energy dissipation was greater in region 2. Elastic modulus and ultimate strength were significantly higher for region 1, and elongation at break was longer in region 2. The fit curve of the 2 regions deviated markedly.

CONCLUSIONS

The biomechanical properties of the upper and lower regions of the lateral SMAS are functionally different. Such knowledge will help refine the planning and design of facial surgery and improve outcomes for patients who undergo rhytidectomy.