Superficial Muscular Aponeurotic System Research Articles

Post-Treatment Displacement of Facial Soft Tissue Fillers-A Retrospective Ultrasound-based Investigation of 382 Zygomatic Regions.

Clinical and ultrasound experience has revealed that after soft tissue injections of the lateral cheek, the filler may displace from the zygoma to the caudal temporal area. To obtain more data to provide insight into product distribution when soft tissue fillers are injected in the zygomatic region. Two hundred patients were examined with facial ultrasound imaging of the zygomatic and temporal region. Inclusion criteria were simply a positive response on the screening questionnaire as to whether or not they had filler injections placed in their lateral cheek. Control injections were also performed to the zygomatic regions of a body donor and in 10 patients ultrasound-guided. A correlation was found between the layers in which filler was detected on the zygoma and where it was ultimately found in the temples. Four different redistribution patterns were observed: (1) migration of filler within the superficial muscular aponeurotic system (SMAS) on the zygoma into the superficial temporal fascia. Migration of filler from the lateral suborbicularis oculi fat to (2) the deep interfacial plane of the temple or (3) to the superficial temporal fat pad; (4) migration from the supraperiosteal layer of the zygoma to the superficial temporal fat pad. Body donor and patients: filler deposits injected on the zygoma were witnessed to shift during injection into the caudal part of the temple. Soft tissue filler aliquots may be redistributed into the temples after injections of the lateral side of the zygomatic arch. The displacement follows a distinct pattern depending on the initial layer of injection.

Comparison of Resorption in Autogenous Dorsal Onlay Cartilage Grafts: An Experimental Study.

The present study was designed to compare the graft resorption characteristics of autogenous cartilage from the septum, auricle, and costal in the superficial muscular aponeurotic system of the nasal dorsum of the rabbit model. Equal-sized perichondrium-free septal, auricular, and costal cartilage grafts were collected from fifteen New Zealand white rabbits. Cartilage grafts were taken at the scale of two grafts from each animal's ear, two from its costal part, and one from its septum. Costal cartilage grafts that were shaped with a micro-motor device and monopolar electrocautery, elastic cartilage grafts that were shaped with a micro-motor device and monopolar electrocautery, and septal cartilage grafts that were shaped with a scalpel were all implanted into the dorsum of rabbit's noses to create five groups. All autogenous cartilage tissues were removed 3months later. Cartilages were evaluated for histological features, graft mass, and chondrocyte density resorption. The elastic cartilage group, where electrocautery was used to shape the cartilage, had a higher resorption score than the other groups. The costal cartilage graft shaped with a micro-motor was also observed to have the best cartilage regeneration score. We observed that the resorption of costal cartilage was lower than that of ear and septum cartilage. It was determined that micro-motor application for the shaping process caused less resorption and stimulated more regeneration than cautery application. 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 .

Eyebrow Lift: Open-Book ROOF Transposition and Orbicularis-Frontalis Sliding Maneuver.

This article delves into innovative surgical techniques, the open-book ROOF (retro-orbicularis oculi fat) transposition technique (OBRoof) and the orbicularis-frontalis sliding maneuver (OFS), designed for eyebrow and upper eyelid rejuvenation in the aging process. Emphasis is placed on understanding the dynamic changes occurring within the forehead and eyebrow envelope's five layers and their intrinsic relationships as well as the impact of the ROOF ptosis causing upper eyelid hooding. The OBRoof technique is highlighted for its effectiveness in addressing ptotic volume, offering a rejuvenated appearance by relocating volume to the supraciliary region.In the OFS, we explore the concept of extensive dissection above the upper border of the eyebrow to allow for free repositioning of the eyebrow. The stabilization is based on deep-plane facelift concepts, as the orbicularis oculi muscle corresponds to the superficial muscular aponeurotic system, and it is anchored to the deep layers (periosteum) by passing through the frontal muscle.In summary, this article provides a comprehensive exploration of innovative and minimally invasive techniques for eyebrow and upper eyelid rejuvenation, shedding light on their anatomical foundations, procedural intricacies, and the potential for achieving natural and lasting outcomes.

Analysis of the Effect of Zygomatic Fat Pad Lifting Combined with Ultra-High SMAS Technique on the Improvement of Nasolabial Folds (Lower Eyelid Margin Incision)

This paper aims to explore the effect of zygomatic fat pad lifting combined with ultra-high superficial muscularaponeurotic system (SMAS) technique on the improvement of nasolabial folds. From December 2021 to June 2022, 40 patients with facial sagging were selected in our hospital to perform zygomatic fat pad lifting combined with ultra-high SMAS technology for large facelift surgery. Combined with lower eyelid incision and zygomatic fat pad degloving, the middle and lower face lift surgery, the improvement of the nasolabial fold, and the reduction of the apple cheeks were evaluated to assess the surgical effect. Statistics were collected on the improvement of nasolabial folds and apple cheeks aesthetic units before and after operation in 40 follow-up patients, and the satisfaction degree of nasolabial fold elevation and apple cheeks reduction was investigated and analyzed. The facial nasolabial folds and apple cheeks aesthetic units of 40 patients were followed-up after operation and compared with those before operation, and the difference was statistically significant (P < 0.05). After surgical treatment, 95% of patients were satisfied with the improvement of nasolabial folds, and 97.5% were satisfied with the reduction of apple cheeks. Zygomatic fat pad lifting combined with ultra-high SMAS technique has a significant effect on the reduction of apple cheeks zygomatic fat pad and nasolabial fold elevation, and it has clinical application value.

MODIFIED COMPOSITE PLANE FACELIFT WITH EXTENDED NECK DISSECTION.

The attenuation of retaining ligaments with aging leads to downward displacement of facial fat compartments, and is responsible for many of the stigmata that occur with aging. The zygomatic cutaneous and masseteric cutaneous ligaments prevent the transmission of adequate traction to the malar portion of the dissection during traditional low SMAS facelift techniques which involve plication or imbrication of the exposed surface of the SMAS because they do not include surgical release of these ligaments. Inadequate release of these ligaments, especially the zygomatic cutaneous ligament may lead to an unbalanced, unnatural appearance with unopposed nasolabial folds. In contrast, extended facelift techniques (extended SMAS, High SMAS, deep plane facelift, composite plane facelift) involving the release of these ligaments and can reposition the ptotic malar fat, and diminish the nasolabial folds. Additionally, the composite and modified composite plane facelifts include orbicularis oculi muscle elevation and can achieve a more harmonious rejuvenation. However, due to facial nerve injury risk, many facelift surgeons either inadequately release these ligamentous attachments or prefer less invasive techniques. Modified composite plane facelift allows safe release of the zygomatic cutaneous ligament, and safe entry into the right plane leaving all malar fat pad attached to the skin. Modified composite plane facelift technique also produces combined, balanced, and harmonious rejuvenation of the midface, cheek, lower face, and neck without requiring a separate midface lift procedure or a transblepharoplasty approach. Extending the subSMAS/subplatysmal dissection inferior to the angle of mandible, releasing of the cervical retaining ligaments, and adding a horizontal platysma myotomy below the angle of the mandible significantly improves the cervical contouring and enhances the jawline rejuvenation. This paper explains modified composite-flap facelift with extended neck dissection in a step by step manner, and highlights anatomical details to perform a safe, effective and successful extended face and neck lift surgery.

The usage of Nd:YAG laser in SMAS lifting of the middle and lower third of the face

The purpose of the work is to improve the quality of vertical face lifting by introducing into surgical practice a laser system of the Fotona SP Spectro model with a Nd:YAG laser source. The technique of intraoperative exposure of the Fotona SP Spectro laser system with an Nd:YAG laser source to the superficial muscular-aponeurotic system (SMAS) of the middle and lower third of the face is proposed. The authors conclude that the use of Nd:YAG laser in a single procedure shortens the rehabilitation period and significantly increases the rejuvenation effect in cases with hypermobile and thinned SMAS.

Facelift Surgery after Permanent Filler: Outcomes after Removal of Permanent Filler under Local Anesthesia.

Background:Permanent fillers were previously used to fix wrinkles associated with aging as they were considered a reasonable choice for facial rejuvenation. However, the subsequent removal of permanent fillers is of great concern to surgeons before performing a facelift surgery. Many studies have evaluated the outcomes of facelift surgery; however, we sought to evaluate the outcomes of facelift surgery which required removal of fillers beforehand.Methods:This retrospective cohort study evaluated the outcomes of 50 patients with regard to patient satisfaction and postoperative complications of facelift surgery with removal of permanent filler under local anesthesia. A short scar rhytidectomy with superficial muscular aponeurotic system plication was performed. Preoperative and postoperative photographs were analyzed by two independent surgeons to report asymmetry scores ranging from one to three (one none, two slight, and three obvious asymmetries). Patient satisfaction scores were also recorded.Results:The preoperative presentations of the permanent filler were asymmetry (82%) and disfiguring facial edema (26%). Removing fillers under local anesthesia is generally tolerable, with 56% of patients tolerating rhytidectomy. The degree of the participants’ satisfaction after follow-up was satisfactory; two-thirds of patients (62%) were satisfied. There was a significant difference between surgeons’ preoperative and postoperative assessment of asymmetry scores (P < 0.05).Conclusions:Permanent filler removal with concomitant face-neck lift surgery has satisfactory outcomes. The procedure length was primarily determined by the patient’s skin characteristics and the severity of the local condition.

Combined sternocleidomastoid and superficial muscular aponeurotic system flap reconstruction after malignant parotid tumor excision: a case report

Combined sternocleidomastoid and superficial muscular aponeurotic system flap reconstruction after malignant parotid tumor excision: a case report

The applications of real-time imaging with transillumination, ultrasound, and Doppler for thread lifting

Thread lifting has gained popularity in recent years because of its minimally invasive properties. Regardless of the technique used, the key is threading in the optimal anatomical plane and suspending the correct target tissue. Failure to meet these objectives may result in chronic pain; contour irregularity; thread migration or exposure; and nerve, vessel, and gland injuries. The knowledge of facial anatomy alone is insufficient to corroborate the anatomical variations of a patient. Ultrasound-guided thread lifting can be performed because the trocar presents a hyperechogenic signal with bayonet and reverberation artifacts. Ultrasound is an effective tool because it can provide real-time images of the layers of the facial anatomy, fat pads, muscles, fascia, ligaments, superficial muscular aponeurotic system, arteries, and parotid duct. Transillumination, however, can be conducted to verify the presence of superficial vessels and prevent venipuncture and injury to homonymous arteries. The combination of transillumination and ultrasound provides three-dimensional information. In this study, to evaluate facial anatomy and guide threading, reconfirm the position of the thread, and prevent malpractices, practical strategies such as transillumination, ultrasound, and Doppler imaging are recommended for improving patient safety during, before, and after the procedure.

A New Approach to Thread Facelifting.

Facial rejuvenation has traditionally been achieved by repositioning soft tissue via invasive surgery. The present work describes a thread-based, face-lifting (TBFL) technique (BussoLyft&trade; that has provided reproducible and predictable results for 200 to 300 patients. To reposition the orbital, nasolabial, and jowl fat pads, three primary vectors (one vertical, two oblique) are established on the side(s) of the face that requires lifting. The vertical vector for the orbital fat pad is volumetric and the oblique vectors for the nasolabial and jowl fat pads lift by thread-tissue engagement and repositioning. Repositioning the superficial fat pads of the orbital, nasolabial, and jowls areas results in a pleasant cosmetic outcome. In the treated nasolabial and jowl fat pads, the primary repositioning vector results from engaging cogs with fat septa, which places fat in a cosmetically optimal position. The primary mobilization of the superficial fat pad through the septal attachments to the dermis and superficial fascia creates a secondary movement and repositions the overlying skin and underlying superficial muscular aponeurotic system (SMAS). Very few threads are needed to reposition full-face superficial fat. By optimizing every step of thread placement, the TBFL technique provides an efficient and effective method to reposition facial fat pads. J Drugs Dermatol. 2021;20(10):1085-1090. doi:10.36849/JDD.6139.

Commentary on: Identifying Regional Viscoelastic Properties of the Superficial Muscular Aponeurotic System.

Commentary on: Identifying Regional Viscoelastic Properties of the Superficial Muscular Aponeurotic System.

Commentary on: Identifying Regional Viscoelastic Properties of the Superficial Muscular Aponeurotic System.

Commentary on: Identifying Regional Viscoelastic Properties of the Superficial Muscular Aponeurotic System.

Facelift Surgery: History, Anatomy, and Recent Innovations.

Facelift surgery has become a beautifully predictable, safe, and extremely effective operation. Our patients can expect natural and long-lasting results as a direct outcome of our improved understanding and applications of surgical facial anatomy. Rhytidectomy, once an operation of simple well-placed elliptical skin excisions, evolved to include longer skin flaps, skin and platysma flaps with various superficial muscular aponeurotic system (SMAS) manipulations, and various deep plane techniques involving the skin and SMAS as a single unit composite flap. Extended deep plane rhytidectomy and vertical vector neck and SMAS lifting have emerged in recent years as techniques that extend the traditional deep plane dissection into the neck in a subplatysmal plane to allow for release of the platysma from the cervical retaining ligaments. This, ultimately, allows for the creation of a dramatically more youthful appearing face, neck, and jawline.

Deep-Plane Approach to the Vertical Platysma Advancement: Technical Modifications and Nuances over 25 Years.

In this article, we will provide the reader with the anatomical and embryologic evidence supporting the use of the deep-plane approach in rhytidectomy and insight into the evolution of the technique into the vertical platysma advancement. The original description of the deep-plane technique only described a basic superficial muscular aponeurotic system dissection in the midface with the ability to use tension on the flap without aesthetic consequences. This plane of dissection provides additional advantages not previously described, including access to deeper anatomical structures such as the buccal fat pad, and allows in vivo assessment and treatment of jowling. We describe how extension of this dissection and selective release of facial ligaments allows us to optimize treatment outcomes and longevity, especially in cases of difficult anatomy or revisions. Further advancements include case-specific facial volume enhancement, created by complex flap design, and facial narrowing by preauricular contouring and parotid hypertrophy treatment. Insights into anatomical landmarks, technical nuances, and alternative approaches for facial variations are presented.

The Facelift in South American Patients.

South America is a vast territory; its people were made from all parts of the world. The miscegenation made a unique population comprised of Indian, Asian, Caucasian, African, Mestizo, Mulatto, and Zambo. The South American patients tend to have a wider face with a skin-soft tissue envelope (S-STE) that is thicker, heavier, and has less elasticity than the Caucasian patient. Upper eyelids may hood easily. In the same way, malar eminences and round face look are more prominent. The chin can be a little retracted. With aging, the S-STE tends to sag more, making nasolabial folds and jowl area more prominent, and redundant neck skin will appear loose and heavy. Facelift is popular in South American patients. They have peculiar characteristics like heavy dark sebaceous skin which lead to peculiarities in face lifting. It is usually a procedure designed to rejuvenate all thirds of the face. In the forehead, skin excision in temporal incisions is usually necessary. Midface subperiosteal lift is a possibility for heavy skin patients who need great improvement in the center of the face. The neck lift is almost indispensable to the rejuvenation of the lower third. Extended superficial muscular aponeurotic system or deep plane dissection is commonly performed so the soft tissues of the midface, the jowls, and the neck can be lifted to reestablish their youthful relationship with the underlying skeleton.

Facelift With Power-Assisted Dissection: A Preliminary Report.

Subcutaneous elevation of the skin has remained a key component in all facelift techniques. The aim of this preliminary report was to introduce the ABC facelift as a 3-step method addressing photodamage, soft tissue laxity, and areas of bone and volume loss. The procedure consists of: (A) anatomic and regenerative adipose grafting prior to skin elevation; (B) the use of a Baraf elevator for takedown of perpendicular subcutaneous fibers following hydrodissection of the skin flaps with tumescent solution; and (C) cautery dissection of the superficial muscular aponeurotic system (SMAS) and platysma in the neck. Thirty-four patients (31 females; 3 male), aged 50 to 77 years at the date of procedure, underwent an ABC facelift. Dissection of the skin flaps and SMAS elevation were faster than with traditional methods, averaging 10 to 15 minutes per hemiface. Bleeding was reduced (average estimated blood loss, 12 mL) and the skin flaps appeared better perfused with less venous engorgement and ecchymosis than achieved with sharp scissor dissection. In general, patients appeared to have shorter postoperative recovery courses and less social downtime secondary to bruising and edema. The ABC facelift addresses facial laxity, volume loss, and skin aging with 3 simple steps: anatomic and regenerative fat grafting, combined with power-assisted dissection of the skin and cautery elevation of the SMAS. The use of more advanced hydrodissection tools to achieve further improvements in layer separation is currently being investigated.

Lateral Superficial Muscular Aponeurotic System Stacking/Superficial Muscular Aponeurotic Systemectomy With Orbicularis-Malar Fat Repositioning: A Procedure Tailored for Female Asian Patients.

Important differences in facial anatomy and how faces age must be considered when performing facelifts in Asian populations. Few facelift methods are specifically designed for Asian patients. This study evaluated the efficacy of lateral superficial muscular aponeurotic system (SMAS)-stacking/SMAS-ectomy with orbicularis-malar fat repositioning. Between February 2013 and December 2016, 62 women underwent the evaluated technique and completed the follow-up (15 months, ranging from 3 to 38.5 months). Three blinded, independent observers graded wrinkles, laxity, nasolabial fold depth, malar prominence, and tear trough deformity using quantitative comprehensive grading scales. FACE-Q scale items were assessed, and complications were recorded. The mean postoperative scores for wrinkles, laxity, nasolabial fold depth, malar prominence, and tear trough deformity decreased from 2.64, 2.62, 2.01, 2.06, and 2.40 to 1.48, 1.34, 0.93, 1.21, and 1.27, respectively. The preoperative and postoperative scores differed significantly for all parameters (p < .05). The FACE-Q results showed that the patients were highly satisfied with their appearance, quality of life, adverse effects, and care. The authors' technique allows midfacial and periorbital rejuvenation and offers dual benefits by correcting individual facial asymmetries and reshaping the jowls and neck contour in Asian patients.

Mini-midface Lift Using Polydioxanone Cog Threads.

Background:Deepening of the nasolabial fold with reduced malar highlight caused by sagging of the midface is one of the most important characteristics of facial aging. This report describes the use of 18-G polydioxanone (PDO) cog threads to improve midface soft tissue sagging and achieve satisfactory results through a minimally invasive procedure.Methods:In total, 64 patients (all women; age, 33–60 years) underwent a midface thread lift from January 2017 to January 2018. After a stab incision was made through an 18-G needle over the lateral orbital rim, three 18-G precannulated PDO cog threads were inserted, targeting the deep medial fat pad and inner layer of the superficial muscular aponeurotic system. The threads were anchored to the periosteum of the lateral orbit, suspending the soft tissue to a more superior direction. Surgical results were evaluated subjectively (patient satisfaction ratings) and objectively (blinded physician ratings based on changes in the vertical position of the malar highlight).Results:No major complications (postoperative hematoma, infection, or temporary sensory/motor decreases) were observed. The mean procedural time was 15 minutes, and all patients underwent local anesthesia. Patient satisfaction was the highest at 1 month postoperatively (mean, 4.7/5.0), decreasing at 1 year postoperatively (2.8/5.0). The scores on the objective assessment followed the same trend (4.5/5.0 at 1 month; 3.1/5.0 at 1 year).Conclusion:Using PDO cog threads for midface lifting is simpler, quicker, and less invasive than using conventional surgical methods, and this method simultaneously achieves satisfactory results for at least 6 months.

Identifying Regional Viscoelastic Properties of the Superficial Muscular Aponeurotic System.

Suspension of the superficial muscular aponeurotic system (SMAS) is generally believed to be necessary in facelift surgery. Although many techniques have been suggested, all rely on the viscoelastic properties of the SMAS. The aim of this study was to determine the viscoelastic properties of bursting strength, stress relaxation, and creep in the lateral, mid-cheek, and medial regions of the SMAS. The viscoelastic properties of the SMAS were determined in 12 cadaveric hemifaces. Lateral SMAS was classified as the SMAS overlying the parotid gland; mid-cheek SMAS as anterior to the parotid and overlying the masseter muscle; and medial SMAS as including tissue extending medial from the lateral canthus and ending at the nasolabial fold. The 3 SMAS regions showed significantly different bursting strengths: 38.9 N for the lateral SMAS, 26.7 N for the mid-cheek SMAS, and 11.9 N for the medial SMAS (P < 0.0001). Stress relaxation was similar in all vertical regions with measurements of 54% in the lateral, 48% in the mid-cheek, and 59% in the medial SMAS. Creep was found to be similar in the lateral and mid-cheek SMAS with values of 18% and 19%, respectively. The medial SMAS was noted to have a higher creep at 22%. The lateral SMAS has a stronger bursting strength than the mid-cheek and medial SMAS. Creep appears to be lower in the lateral and mid-cheek SMAS. Stress relaxation appears to be similar in all 3 vertical regions.

Superficial Muscular Aponeurotic System–Pedicled Flaps for the Reconstruction of Facial Defects: Clinical application and Anatomical Basis

Application of distant skin flaps in facial defect reconstruction has limitations such as leaving a patch like appearance and being restricted by the length of the vascular pedicles. Leveraging the abundance of blood supply from superficial muscular aponeurotic system (SMAS), a local skin flap pedicled by SMAS can be used to avoid the aforementioned problems. Herein, we report the clinical application as well as the anatomical study of SMAS-pedicled skin flaps. This study enrolled patients who underwent facial defect reconstruction surgery between 2013 and 2018 using SMAS-pedicled skin flaps. The flaps were designed according to the size and location of the defect. A follow-up was performed to evaluate the treatment outcomes and incidence of adverse events. In addition, six cadaveric heads were used to perform an anatomical study on the distribution and blood supply of SMAS. Twenty-three cases underwent the defect reconstruction surgery in the frontal regions (three cases), temporal region (four cases), periocular region (four cases), nasal region (seven cases), and other regions (five cases). All the flaps survived well. During the follow-up period up to 12 months, the flaps showed a satisfactory appearance, blood supply, and elasticity. The distribution and blood supply of SMAS at different anatomical regions have been successfully observed. Abundant vascular networks could be found in the SMAS layer. Based on the broad distribution of SMAS and the abundant blood supply, an SMAS-pedicled skin flap could be flexibly designed and versatilely used to reconstruct post-traumatic or post-excisional facial defects.