SMAS Plication Facelift

A thorough understanding of facial anatomy is essential in performing facial rejuvenation surgery. For the new surgeon undertaking cosmetic surgery of the face and neck, superficial musculoaponeurotic system (SMAS) plication is a less complex way to begin. This technique offers a reliable and consistent way to rejuvenate the lower face and the neck, and compared with more invasive procedures, the potential for complications may be reduced. The technique is also adaptable to a given patient's anatomy. 

The term rhytidectomy is synonymous with facelift. Rhytidectomy is derived from the Greek words rhytis, meaning wrinkle, and ektome, meaning excision. Dorland's Illustrated Medical Dictionary defines rhytidectomy as "excision of skin for the elimination of wrinkles." ^[1] Rhytidoplasty is defined in the same text as "plastic surgery for the elimination of wrinkles from the skin." ^[1]  Certainly, rhytidoplasty seems a more comprehensive term, since resecting the skin is not the only way wrinkles are reduced or eliminated. ^[2]

Historically, facelifting consisted of elevating the skin, placing it under tension to reduce the wrinkles, resecting the skin needed to accomplish this, and then securing the resected edges. However, over time, facelift surgery evolved beyond the Dorland's definition of "rhytidectomy" and now is defined more by "rhytidoplasty." The array of plastic surgery techniques used in facelifting encompasses different depths of dissection and variation in approaches. These depths and approaches are denoted by terms such as deep plane, subperiosteal, composite, subdermal, endoscopic, mini-incision, and laser-assisted, with there being various SMAS approaches besides. ^[3]

Permanent and nonpermanent sutures, threads, ribbons, and implants have also been utilized to assist in facelifting surgery. Noninvasive modalities such as ablative, nonablative, and sublative skin resurfacing can enhance the outcome by improving the exterior texture of the skin and stimulating collagen growth. ^[4] Dermal and subdermal fillers can also be used adjunctively and, in some cases, can substitute for a rhytidectomy. Additional modalities include radiofrequency, ^[5] dual-frequency radiofrequency, ^[6] multipolar radiofrequency with magnetic pulses, and ultrasound.

The understanding of facelifts has evolved to include the realization that tissue elevation and resuspension or support of the deeper tissue layers (ie, those beneath the skin) are essential for obtaining significant and lasting changes. However, even the latest facelift surgery cannot reduce all rhytides. Supplemental treatments of the more superficial aspects of the skin often are required. These can be in the form of chemical peels, dermabrasion; microdermabrasion; filler substances including autogenous, homogenous, or synthetic material; and laser resurfacing (both ablative and nonablative). Newer alternatives include microneedling and radiofrequency (RF) microneedling.

Minimally invasive treatments using RF, such as FaceTite (InMode Ltd) and ThermiTight (ThermiHealth LLC), and RF with helium plasma, such as Renuvion and J-Plasma (Apyx Medical), do not directly tighten the SMAS but instead work through collagen remodeling and tightening of the fibroseptae.

This article discusses the SMAS plication technique in facelift surgery. Plication is defined as a fold, the process of folding, or the state of being folded.

Skoog used the treatment of the SMAS as a tool in the armamentarium of facelifting techniques in 1969. ^[7] Lemmon notes that he described a sub-SMAS dissection used during rhytidectomy as a "useful technique in facelifting." ^[8] In 1976, the anatomic work of Mitz and Peyronie ^[9] described the SMAS based on encouragement from Tessier.

Since then, numerous authors have added to the literature and instruction courses on manipulating the SMAS. The treatment of the SMAS entails resuspending it, resecting it, plicating it, or a combination of all 3 techniques.

Often rhytidectomy is desired to reverse the gravitational effects leading to rhytidosis of the facial skin and loss of subcutaneous support. Additionally, patients suffering from facial palsy, such as a persistent severe Bell palsy, may desire a facelift to counteract the resultant facial droop.

Psychosocial issues often are involved when patients seek facial rejuvenation. Understanding the patient's motivation for and expectations from the surgery is a key factor in successful surgery. Discussing such issues with the patient during the preoperative assessment is imperative.

Frequency

According to the American Society of Plastic Surgeons (ASPS), 72,668 facelifts were performed by ASPS member surgeons in 2022, an 8% increase over the number performed in 2019, prior to the coronavirus disease 2019 (COVID-19) pandemic. ^[10]

Using data from the American Board of Plastic Surgery, a report by Stein et al found that out of 3400 facelifts performed between 2006 and 2021, 40% of SMAS rhytidectomies were carried out using plication. SMAS procedures also involved using flaps (35%), SMASectomy (22%), and minimal access cranial suspension (MACS) lift (6%). ^[11]

Age

According to the ASPS, about 60% of the facelift procedures performed by its member surgeons in 2022 were carried out on patients aged 55-69 years. ^[10]

Gravitational effects, loss of skin turgor with collagen breakdown, and loss of elasticity exacerbated by sunlight exposure result in facial rhytidosis. A high degree of variability exists in these changes based on sex, ethnicity, sunlight exposure, and other factors. Various nonsurgical treatment modalities can slow the progress of these inevitable ravages but cannot forestall them forever. Addressing the underlying tissues also has been advocated with the use of specific facial exercises and electrocurrent-producing devices causing muscular contraction.

In addition to skin changes, absorption of the buccal fat pad and shrinkage or resorption of the skull occur as individuals age into the sixth decade. This process continues over time. Other changes have an earlier onset. For example, the brows start their downward descent in the third to fourth decades.

Patients who present for facelift surgery can be in the third to tenth decades. However, the usual range is from the late fifth decade to the late seventh decade. Females seek facelift surgery more often than males. However, all of these statistics are changing. Often patients present with a combination of facial rhytidosis, sagging skin of the neck, neck bands, submental fat, hollowed out cheeks, jowls, and deep melolabial (nasolabial) folds. These presentations vary depending on the age, sex, and ethnicity of the patient.

Some patients already have had surgery years ago and desire repeat surgery to maintain the effects that have changed and diminished over time.

Preoperative photographs are helpful in addressing the areas of concern to the patient and are important from a medicolegal perspective. Postoperative photographs also should be taken, mimicking the preoperative photos in view, lighting, expressions, and lack of makeup for easier comparison. Frontal, lateral, and oblique photos of the face and neck usually are obtained with either a digital camera or, less commonly, a 35-mm film camera. Computer imaging systems are available to record these photos and allow for changing the preoperative photo to simulate the postoperative effect. However, having used one, the authors have found its best use to be that of a photo archiving device.

Rhytidectomy seeks to improve facial rhytidosis and overall sagging of the skin and deeper facial layers. These changes can include blunting of the cervicomandibular angle and jowl formation, cheek laxity and absorption of the buccal fat pad, neck laxity, neck bands, a large neck, and prominent melolabial (nasolabial) folds.

As mentioned earlier, patients with facial palsy also may seek unilateral facelift surgery.

Ideally, patients are thin, fair-skinned, and middle-aged, with moderate-to-severe skin laxity. Individuals who are overweight or have thick skin tend to have a slightly less optimal outcome.

Regardless of one's preference of surgical technique, a thorough understanding of the cervicofacial anatomy is essential, and this anatomy should be reviewed.

The human face is a magnificently complex structure that can challenge any surgeon. In particular, one must firmly understand the blood supply and the rapport of the skin, fascia, fat, musculature, and periosteum in the cervicofacial area.

The skin, superior to the zygoma, has a robust blood supply emanating from the superficial temporal artery. Below the zygoma, the facial and the transverse facial arteries provide blood flow to the skin before anatomization with the superficial temporal artery in the subdermal region. These 3 vessels emerge from the external carotid artery, while other tributaries originate from the internal carotid artery and include the supraorbital and supratrochlear vessels.

The superficial fascia of the face and neck overlying the parotid and cheek area is referred to as the SMAS (ie, superficial muscular and aponeurotic system). As defined by www.plasticsurgery.about.com, SMAS is "an abbreviation for sub-muscular aponeurotic system—a layer of tissue that covers, surrounds and attaches to the deeper tissues and structures of the face and neck, including the entire cheek area. It also attaches to the platysma—the superficial muscle covering the lower face and neck." ^[12]

This system has an extensive domain, with most authors acknowledging the galea as its superior extension and the intermingling with the platysma as its lowermost extension.

As the SMAS courses over the deep temporal fascia, it is commonly labeled the temporoparietal fascia or superficial temporalis fascia. It contains the superficial temporal artery and frontal branch of the seventh cranial nerve, which easily can be insulted during dissection and retraction in the region of the zygoma. The temporal branch of the facial nerve courses over the zygomatic arch anterior to it. Variability has existed in the number of nerve rami and the pattern of this, often referred to as a singular "branch." At the level of the zygomatic arch, the attachments of the SMAS vary and tend not to be contiguous.

As the SMAS moves inferiorly, it passes over the parotid gland. Jost and Levet feel that the SMAS is included in the parotid fascia. ^[13] The SMAS is attached to the deep fascia and skin via parotid-cutaneous, ligament-like tissue projections. The SMAS courses anterior to the masseter muscle and then dives down to envelop the muscles of facial expression. A thinner layer of the SMAS invests the undersurface of the skin of the face. The buccal branches of the facial nerve are in a sub-SMAS distribution in this locale and should not be disturbed during dissection.

Contraindications to facelift surgery are presented by patients who are not good candidates from a psychosocial perspective. Motivations for the surgery and realistic expectations are important considerations, and answers to questions regarding those items may negate performing the surgery. Performing the surgery on patients who smoke ideally should be deferred until smoking cessation has been achieved, although an alternative technique requiring a smaller subdermal flap may be warranted. Patients with collagen vascular diseases, keloid formation, bleeding abnormalities, diabetes, prior facial radiation, or other conditions that contribute to hematoma formation and poor wound healing should be counseled appropriately.

Other contraindications include inability to tolerate the surgery or anesthesia from a medical point of view. Patients taking aspirin and vitamin E should discontinue use 2 weeks prior to surgery. Patients using traditional nonsteroidal anti-inflammatory drugs (NSAIDs) should discontinue use 7 days prior to surgery.

It is imperative that the patient not smoke or be exposed to secondary smoke, to avoid compromising the blood supply and causing tissue necrosis or other complications. Surgeons vary with regard to how long a patient must stop smoking before surgery, and this period can range from weeks to months. Additionally, the patient must adhere to this requirement postoperatively. If needed, a smoking cessation program can be implemented with the appropriate providers. Not only will this diminish the risk of complications, it will also benefit the patient’s overall health. SMAS plication with a short skin flap can also reduce the risk of skin necrosis, as the separation between the skin and underlying vascular tissues is reduced. However, even with the use of short flaps, smoking cessation necessary.

As with any facelifting procedure, patient safety is of the utmost importance in the SMAS plication facelift, although most patients do well with the surgery. Patient selection is important, as is setting realistic patient expectations and tailoring the procedure to an individual's needs. For example, a patient with a very obtuse angle and a low hyoid may benefit from a modification of the surgery or adjunctive procedures such as a chin implant, if there is retrognathia (recessed chin).

Injury to the marginal mandibular nerve can occur in any facelifting surgery; with SMAS plication, however, the initial dissection plane is subcutaneous, and the deeper location of the nerve is avoided. The more superficial aspect of the nerve is also avoided, as the dissection does not involve the area where the nerve takes a more superficial path.

In a study of “platysma-SMAS plication facelift” procedures, Berry and Davies found that, using a 5-point scale to assess cosmetic outcome, 82.2% of scores at final follow-up matched or improved upon the initial follow-up scores. ^[14]

In a cadaveric study, Rao et al found that the vertical and horizontal vectors of the face underwent greater composite lifts from SMAS plication and extended SMAS procedures than they did from skin-only lifts. The investigators also reported that greater lift in the lower face was obtained by the extended SMAS technique over SMAS plication. ^[15]

Patient expectations must be in line with the rejuvenation that can be achieved through an SMAS plication facelift. The surgery will improve the contour of the neck and jawline, but it will not reduce all wrinkles or improve dyschromia. (In appropriate patients, however, the operation can be combined with other procedures, such as a chemical peel or laser resurfacing, as long as the blood supply to the skin is not compromised.)

Patients heal differently, and expectations must be tempered to the individual situation. It is imperative that good communication exists between the patient and the entire care team to achieve the best outcome. Most importantly, the patient must understand that, while facial plastic surgery will change the individual's appearance, it will not change his or her life. Patients must be aware of the limitations of surgery and that the facelift in and of itself will not improve their lives or make them “feel better” about themselves. Realistic expectations must be conveyed and discussed between the patient and the surgeon.

In addition, patients with body dysmorphic disorder (BDD) need to be identified. When necessary, referral for counseling and other supportive measures can be implemented. A study from the Netherlands, by Vulink et al, reported that in the outpatient plastic surgery clinic of a university medical center, the 6-month prevalence of patients with BDD was 3.2%. ^[16]  American cosmetic surgery samples have put the rate of patients with BDD at 7-8%. ^[17]