Superficial Musculoaponeurotic System Facelift Research Articles

Temporal Incision Super-high Superficial Musculoaponeurotic System Face Lift for Chinese Patients.

This investigation assessed patient satisfaction with a temporal incision technique using a super-high superficial musculoaponeurotic system (SMAS) flap for midface lifting in a Chinese patient cohort. From July 2019 to July 2023, 95 patients underwent midface lifts via a temporal incision approach at our institution. The extent of SMAS flap dissection spanned 2 cm above the outer canthus, to the lower margin of the zygomatic arch inferiorly, and medially to the zygomaticus major muscle. The technique involved anchoring the elevated SMAS flap to the deep temporal fascia to elevate the malar fat pads, correct sagging tissues, and ameliorate the appearance of nasolabial folds. Among the 95 patients, 61 completed a follow-up ranging from 6 months to 2 years postsurgery, with a majority reporting satisfaction with the aesthetic results of their midface lift. No significant complications, including permanent facial nerve injury, were reported. The temporal incision super-high SMAS face lift technique demonstrated high patient satisfaction and clinical effectiveness in improving the appearance of nasolabial fold and midface aesthetics. However, the success of this technique hinges on a comprehensive understanding of facial anatomy due to the confined operative field, highlighting its technical demands and the need for surgical expertise.

Cutaneous Layer and SMAS Suspension (CaSS) Lift as a Minimally Invasive Lateral Midface Lift.

In our prior study, the authors determined that pulling on the superficial adipose layer is more effective in lifting the skin than pulling on the superficial musculoaponeurotic system (SMAS). Applying this concept of using the superficial adipose layer to transmit the lifting force to the skin, this study examined improvements in patients who underwent lateral midface lifting using our minimally invasive multilayer lifting technique and measured the duration of those improvements. Along the hairline in front of the sideburns, a W-shaped zigzag incision of 3 to 8mm in width and 3 to 4cm in length was made. On the temporal scalp, 3 to 4cm away from the first incision, a second incision was made more lateral/posterior to the first incision, and an elliptical excision of 3 to 5mm in width and 3 to 4cm in length was made. From the medial cut margin of the anterior first incision, the superficial temporal fascia/SMAS (the deep layer), and the superficial adipose layer (the superficial layer) were purchased with 3-0 polyester sutures, tunneled under the soft tissue, and fixed to the deep temporal fascia of the second posterior temporal incision. Prior to the excised temporal scalp closure, the dermis in the medial cut margin of the second incision was pulled to the rear as much as possible and fixed to the deep temporal fascia. The effects of surgery were monitored for 6 to 42 months after surgery. The nasolabial folds were improved. Skin elasticity also showed significant improvements, which lasted throughout the follow-up period (up to 42mo). Unlike traditional wide dissection SMAS facelift, our method requires minimal incisions and does not require skin undermining. Therefore, the operating time is shorter, and postoperative swelling is minimized. In our technique, the superficial adipose layer, the superficial temporal fascia/SMAS, and the dermis were pulled individually to lift all layers of the lateral midface soft tissues. This results in a significant and long-lasting lateral midface rejuvenation.

Artificial Intelligence in Surgical Evaluation: A Study of Facial Rejuvenation Techniques.

Aesthetic facial surgeries historically rely on subjective analysis in determining success; this limits objective comparison of surgical outcomes. This case study exemplifies the use of an artificial intelligence software on objectively analyzing facial rejuvenation techniques with the aim of reducing subjective bias. Retrospectively, all patients who underwent facial rejuvenation surgery with concomitant procedures from 2015 to 2017 were included (n = 32). Patients were categorized into Groups A to C: Group A-10 superficial musculoaponeurotic system (SMAS) plication facelift (n = 10), Group B-SMASectomy facelift (n = 7), and Group C-high SMAS facelift (n = 15). Neutral repose images preoperatively and postoperatively (average >3 months) were analyzed using artificial intelligence for emotion and action unit alterations. Postoperatively, Group A experienced a decrease in happiness by 0.84% and a decrease in anger by 6.87% (P >> .1). Group B had an increase in happiness by 0.77% and an increase in anger by 1.91% (P >> .1). Both Group A and Group B did not show any discernable action unit patterns. In Group C, the lip corner puller AU increased in average intensity from 0% to 18.7%. This correlated with an average increase in detected happiness from 1.03% to 13.17% (P = .008). Conversely, the average detected anger decreased from 14.66% to 0.63% (P = .032). This study provides the first proof of concept for the use of a machine learning software application to objectively assess various aesthetic surgical outcomes in facial rejuvenation. Due to limitations in patient heterogeneity, this study does not claim one technique's superiority but serves as a conceptual foundation for future investigation.

The Fundamental Concepts of High SMAS Facelift: Literature Review

A number of facelift procedures have been introduced by many surgeons but there is no consensus has yet been established to carry. Since the first description of superficial musculoaponeurotic system (SMAS), it is used as the basis for many facelift methods that produce superior result in rejuvenation compared to traditional skin only facelift. Extended SMAS facelift becoming SMAS modification techniques that is still being developed. It produces two different vector of subcutaneous and SMAS flap, that is essential to restore drooping deep facial tissue with natural appearance. Despite the beneficial use of extended SMAS flap, most of plastic surgeons still traditionally incise the SMAS under the zygomatic arch. However, the low SMAS incision results only on rejuvenation of the lower face and is not sufficient to correct mid-facial aging. Fundamental concepts of high SMAS facelift by reviewing some literatures explain that high SMAS flap transection allowing the surgeon to achieve greater vertical elevation of the deep structures of the face by undermining the middle face, combined with fixation to a fixed structure produces lasting results and oblique vector of skin envelope creating no tension look. Incision above zygomatic arch turns out to be safely performed without facial nerve injury thorough knowledge of the anatomy. The final result is a balanced and harmonious elevation of sagging tissues of the midface, cheek, and jawline, to such an extent that high SMAS facelift becomes optimal, durable, technically simple, reproducible and with a comparatively high safety margin in facelift procedures.

High SMAS Facelift: Combined Single Flap Lifting of the Midface, Cheek, and Jawline

The traditional deep plane and "low" cheek superficial musculoaponeurotic system (SMAS) flaps elevated below the zygomatic arch suffer the drawback that they cannot, by design, exert an effect on tissues of the midface and infra-orbital region. Traditional deep plane and low designs target the lower cheek and jowl only and produce no improvement in the upper anterior cheek and "midface" area. Planning the flap "higher," along the zygomatic arch, and extending the dissection medially in an "extended SMAS" fashion to release and mobilize midface tissue, overcomes this problem and allows a combined, simultaneous, single flap lifting of the jawline, cheek, and midface. An improved outcome is obtained in many patients and no separate midface lift procedure is needed.

Quantifying the Effective Lift of Skin-Only, SMAS Plication, and Extended SMAS Face-Lift Techniques in a Cadaveric Study.

Rhytidectomies are performed to rejuvenate the aging face. Various techniques exist to achieve soft-tissue elevation and skin tightening. This study analyzes three common face-lift techniques: skin-only, superficial musculoaponeurotic system (SMAS) plication, and extended SMAS lifts. The authors characterize effective facial changes with each procedure in a cadaver model. The authors performed face-lift procedures on 18 cadaver hemifaces. Each face was measured along horizontal and vertical vectors. The primary outcome was change along these vectors. Skin-only, SMAS plication, and extended SMAS lifts were performed sequentially on each hemiface. SMAS plication was used to approximate a lateral SMASectomy procedure. Parameter measurements were compared. All three procedures exhibited a significant tightening along horizontal vectors. SMAS procedures provided a significant lift along all vertical vectors, whereas the skin-only lift failed to demonstrate significant vertical elevation. SMAS procedures achieved significantly greater composite horizontal and vertical lifts compared to the skin-only operation. There was only an incremental increase in lift between the SMAS plication and extended SMAS procedures in the upper and midface regions. The extended SMAS led to the greatest lift in the lower face. SMAS procedures provided a greater lift along both horizontal and vertical vectors than the skin lift alone. The increased dissection in the extended SMAS technique resulted in only a modest increase in lift compared to SMAS plication. The extended SMAS approach appears to offer the most benefit at the lower face and may be the best choice for targeting this region.

Extended Superficial Musculoaponeurotic System Face-Lift With Vertical Vector for Asian Patients: A 3-Dimensional Analysis of Facial Contour.

In this study, the authors report the experience of extended superficial musculoaponeurotic system (SMAS) face-lift with the vertical vector in Asian ethnicity and investigate the 3-dimensional change of facial contour. A total of 32 patients with Korean ethnicity underwent extended SMAS face-lift with vertical vector from 2015 to 2018. Patients with aging face were included for the study subjects, whereas those who were diagnosed with any craniofacial deformity were excluded. Using 3-dimensional photogrammetry, surface contour analysis was performed in the cheek region to calculate the mean, maximal, and minimal difference of surface projection and global root mean square error between the preoperative and 1-year postoperative period. The change of horizontal facial widths and jawline angle was evaluated. In contour analysis, the mean difference of surface contour was highest in anterior, followed by lateral cheek and lower face, sequentially. The maximal difference of surface contour was highest in anterior cheek, followed by lateral cheek and lower face, whereas the minimal difference of surface contour was lowest in lower face, followed by anterior cheek and lateral cheek, sequentially. No significant differences in the midfacial and lower facial distances were observed between the preoperative and postoperative periods. There was significant increase of jawline angle, from 20.78 to 23.14 degree of mean value ( P =0.001). In conclusion, the extended SMAS face-lift with vertical vector can be an optimal option for Asian subjects in terms of the midfacial volumetric shift, sharpening of jawline and avoidance of midfacial widening.

The Effect of Extended SMAS Face-lift on Earlobe Ptosis and Pseudoptosis

In this study, we explore the changes in the earlobe segments following an extended superficial musculoaponeurotic system (SMAS) face-lift and neck lift. We proposed to delineate the effect of the cheek and neck skin tension vectors on the earlobe based on the amount of excised skin length. A retrospective study identified patients who underwent extended SMAS rhytidectomy performed by the senior author (A.M.) at the Cosmetic Plastic Surgery Institute (CPSI) from 2017 to 2020. A total of 34 North American Caucasians, who had preoperative and postoperative photographs available for comparison, were evaluated. Preoperative and postoperative cephalic (the distance from the intertragal notch to the otobasion inferius, abbreviated as I to O) and caudal earlobe segment (the distance from the otobasion inferius to the subaurale, abbreviated as O to S) heights were collected. The change from the postoperative to preoperative measurements was calculated. The effects of the degree of cheek skin (superior ear [SE]) and neck skin (mastoid peak [MP]) excision lengths were then determined by comparing the change in I to O and O to S. The postoperative attached cephalic segment (15.94 ± 1.02 mm) increased significantly compared with the preoperative attached cephalic segment (12.99 ± 1.03 mm). The postoperative free caudal segment (3.62 ± 0.81 mm) decreased significantly compared with the preoperative free caudal segment (5.44 ± 0.95 mm). The SE median was found to be 3.0 cm and the MP median was found to be 3.5 cm. I to O increased by 3.85 mm for SE ≤3.0 cm compared with only 1.57 mm for SE >3.0 cm. O to S decreased by 2.79 mm for SE ≤3.0 cm compared with only decrease of 0.14 mm for SE >3.0 cm. I to O increased by only 1.67 mm for MP < 3.5 cm. O to S decreased less dramatically by 0.55 mm for MP ≤3.5 cm compared with decrease of 2.39 mm for MP >3.5 cm. These data demonstrate that more aggressive SE >3.0 cm cheek excision lengths resulted in a protective effect on decreasing the free caudal segment of the earlobe. More aggressive excisions of the cheek demonstrate a protective effect on preserving the free earlobe caudal segment, whereas more aggressive neck skin excisions result in higher propensity for loss of the free earlobe caudal segment. In our study, we demonstrate findings observed with clinical observations that a face-lift and neck lift will result in increase in the attached cephalic earlobe segment height (I to O) and a decrease in caudal free earlobe segment height (O to S). These findings may assist plastic surgeons when trying to fine-tune the earlobe aesthetics during face-lift and neck lift. If the patient has a small free hanging earlobe, the more aggressive pull on the cheek flap will result in less reduction in the earlobe hang.

Is It Possible to Measure the Amount of the SMAS Face Lift According to Facial Vectors?

Since the initial description of the importance of the superficial musculoaponeurotic system (SMAS) in the face-lift procedure, surgical treatment of the facial aging through SMAS face lift evolved to be less invasive, mainly because of potential temporary or permanent facial nerve damage1 with disturbance of the normal function of facial muscles, which could require reconstruction such as the transplantation of subunits of the latissimus dorsi muscle.2 When treatment of the SMAS involves plication, there is a consensus that the SMAS face lift must be performed superiorly and posteriorly; regardless of the technical choice, the concept of the facial vectors is well established.1 The main superior vectors are performed parallel to the body of the mandible, at the level of the projection of the zygomatic arch, and the posterior ones are performed along the projection of the ramus of the mandible. The convergence of these two vectors generally occurs at the preauricular area in the level of projection of the root of the helix, resulting in an inverted-L shape or a 7 shape with an oblique final vector.3 Considering all of the different types of faces and deformities, the distance between the two horizontal and vertical vectors and, consequently, the amount of SMAS lift, will vary according to each patient.1,3 Real et al. described a technique of frontotemporal minilifting using the concept of facial vectors and, based on anatomical points, quantified the amount of eyebrow tail suspension.4 For the past 10 years, the preferred technique for face lift in our group has been the plication of the SMAS, with its imbrication to return volume to the malar area. After skin dissection, the SMAS is marked as described above with two parallel 7-shaped figures, according to the maximum traction possible by both main vectors (Fig. 1).Fig. 1.: Vectors of the two parallel 7-shaped figures at the third middle of the face (arrow indicates the oblique final vector according to the maximum traction of the SMAS).Considering the theory of vector sum, it can be noted that the arrangement of the vectors as two 7-shaped figures enables calculation of the difference between the areas of each one, through the parallelogram law. The so-called parallelogram law gives the rule for vector addition of two or more vectors. For two vectors a and b, the vector sum a + b is obtained by placing them head to tail and drawing the vector from the free tail to the free head. In Cartesian coordinates, vector addition can be performed simply by adding the corresponding components of the vectors; therefore, A = (a1, a2, …, an) and B = (b1, b2, …, bn).5 Therefore, this rule could be applied when there is an overlapping of two geometric figures (Fig. 2). In theory, this numeric value could direct surgeons to estimate the amount of SMAS traction in each patient and then evaluate the effectiveness of the procedure. This idea has been developed and incorporated in the routine of our face-lifting procedures and the results will be presented soon.Fig. 2.: Overlapping of the two geometric figures according to the parallelogram law. The difference between their areas will predict the total amount of lifting.DISCLOSURE The authors declare that they have no commercial interest in the subject of study or in the source of any financial or material support. Marcus Vinicius J. Barbosa, M.D., Ph.D.School of MedicineMorphofunctional LaboratoryMorphofunctional Laboratory Tiago Bianchi, Ph.D.IBM Fabio X. Nahas, Ph.D., M.B.A.Lydia M. Ferreira, M.D., Ph.D.Department of SurgeryDivision of Plastic SurgeryFederal University of São PauloSão Paulo, Brazil

Fat Grafting to Improve Results of Facelift: Systematic Review of Safety and Effectiveness of Current Treatment Paradigms

Autologous fat grafting is a helpful supplement to facelift surgery that helps to combat age-related volume loss of facial structures. Despite the widespread prevalence of combined facelift and fat-grafting, significant procedural variation exists between providers. The primary purpose of this systematic review was to study the efficacy and complication rates of facelift with lipofilling compared with facelift alone. A systematic review of the Cochrane Library and MEDLINE databases as completed was undertaken to identify all clinical reports of fat grafting combined with facelift surgery based on the following key terms: ("fat grafting" OR "lipotransfer" OR "lipofilling" OR "fat transfer") AND ("facelift" OR "rhytidectomy" OR "SMASectomy" OR "facial rejuvenation"). Data on techniques, outcomes, complications, and patient satisfaction were collected. The systematic review was performed in April 2017. In total, 248 articles were identified for review. After application of exclusion criteria, 15 primary studies were included in this review. Various facelift techniques were reported, including deep-plane or sub-superficial musculoaponeurotic system (SMAS) facelift, SMAS facelift, modified minimal access cranial suspension lift, component facelift, midface lift, SMAS plication, SMAS-stacking/SMASectomy, and SMASectomy. The most common locations of fat graft injection included the nasolabial folds, tear troughs, temporal regions, midface/cheek/malar eminence, marionette groove, lips, and ear lobes. The addition of fat grafting to facelift surgery resulted in significant improvements in facial volume and aesthetic assessments. Combined facelift and fat grafting is a safe and efficacious means to simultaneously address age-related ptosis and volume loss. Further research is required to validate and improve existing treatment modalities.

The Superficial Musculoaponeurotic System Facelift: A Prudent Balance of Risks and Benefits.

AbstractOver the decades, facelifting has not escaped the natural history of trends and fads. And, as a profession, facial plastic surgery has not avoided falling into the trap of following corporate initiated technology, rather than leading common-sense methodologies to rejuvenating the aging face. The author is often reminded of a truism to which he was introduced in the 1980s. “When there are many ways of doing things, all of them work; or none of them work.” Undeniably, any procedure that lifts and removes excessive skin of the face and neck “works.” However, the questions that must be answered by leading teachers of facelifting surgery are: How well does a given technique work? How long-lasting are the results? Where does the risk–benefit curve cross over from optimal benefits to unacceptable risks? At what stage in a given patient's aging process are more aggressive techniques called for? At what stage in a surgeon's career should more invasive techniques be attempted, if ever? This article addresses the preceding questions as they relate to the contribution made by the superficial musculoaponeurotic fascia in repositioning sagging tissues of the face and neck.

Commentary on: High superficial musculoaponeurotic system facelift with finger-assisted facial spaces dissection for Asian patients.

I have been asked to write a discussion of the article entitled “High Superficial Musculoaponeurotic System Facelift With Finger-Assisted Facial Spaces Dissection for Asian Patients” by Drs Ryu and Moon.1 The authors stated that few facelift procedures are designed specifically for Asian patients and that the facial characteristics of Asian patients make it difficult to achieve satisfactory results. After their study, they concluded that more studies are needed to redefine suitable facelift techniques for Asian patients. The authors' description of their surgical technique is comprehensible and concise, their diagrams are clear and support their surgical description, and their intraoperative photographs help to illustrate the procedures that they described. There are pre- and postoperative photographs of 2 patients that show aesthetic improvements. However, both sets of photographs make it impossible to ascertain the portion of the result that is purely related to the facelift technique described because both patients have had fat injections in multiple areas of the face, including the upper medial malar area, the nasolabial folds, and the cheeks. Of the 53 consecutive patients who underwent facelifts using the high superficial musculoaponeurotic system (SMAS) with finger-assisted facial spaces dissection technique, 40 patients underwent fat grafting, 11 patients underwent brow lifts, 7 patients underwent upper blepharoplasty, 13 patients underwent lower blepharoplasty, and 18 patients underwent submentoplasty in medial platysmarrhaphy and subplatysmal fat debulking. A brief summary of the authors’ technique is as follows: After skin flap elevation, an incision was …

Consideration of Facelift Methods and Facial Retaining Ligaments in Asians

The demand for facelifts is rapidly increasing in Asia because of economic development as well as the aging of the population. It is difficult to achieve satisfactory results, because of the facial characteristics of Asians. The goal of the facelift is to improve facial sagging. During initial stages, facelifts focused on the lower face. Various approaches, such as the extended superficial musculoaponeurotic system (SMAS) facelift, the finger-assisted malar fat elevation (FAME) facelift, and the high SMAS facelift, were designed to improve facial sagging in the midand lower face with the development of advanced facial surgical procedures [1-5]. Retaining ligaments is important for facelifts and was described by Furnas in 1989, because these ligaments support the soft tissue in its normal anatomical position and resist gravitational effects [6]. These structures attach the dermis, SMAS, and subcutaneous tissues to deep structures such as underlying muscle, bone, and parotid glands. There are two ligament systems. The first comprises true osteocutaneous ligaments: the orbital, zygomatic, and mandibular ligaments. The second involves tethering structures that do not originate from bone but attach the SMAS layer to the deep fascia: the parotid cutaneous and masseteric cutaneous ligaments. With aging, attenuation of retaining ligaments leads to the gravitational Min-Hee Ryu

Surgical Anatomy of the Middle Premasseter Space and Its Application in Sub–SMAS Face Lift Surgery

The premasseter space is a recognized, sub-superficial musculoaponeurotic system (SMAS) soft-tissue space overlying the lower masseter immediately anterior to the parotid. The performance, safety, and effectiveness of composite face lifts are enhanced when the space is used. This has drawn attention to the need for better understanding of the premasseter anatomy above the space. The anatomy of the upper premasseter region was investigated in 20 fresh cadaver dissections as well as intraoperatively in hundreds of composite face lifts. A small, transverse, rectangular soft-tissue space overlies the upper masseter and was named the middle premasseter space. The space (transverse width, 25 to 28 mm; vertical width, 10 mm) is separated from the originally described (lower) premasseter space by a double membrane. It is a safe space between the upper and lower buccal trunks of the facial nerve, which are immediately outside the space and separated from it by the respective upper and lower boundary membranes. The parotid duct immediately beneath the floor of the space usually underlies the upper boundary membrane. The middle premasseter space is significant, as it is the center of the key anatomy immediately cephalad to the lower premasseter space. When used in composite face lifts, the space provides predictable sub-SMAS dissection between the buccal trunks of the facial nerve to the mobile area beyond the anterior border of the masseter where the SMAS overlies the buccal fat pad.

Nasolabial fold augmentation with SMAS graft

This case report shows a new technique for inserting superficial musculoaponeurotic system (SMAS) tissue as autologous filling of deep nasolabial folds during an SMAS or minimal access cranial suspension (MACS) facelift procedure with satisfying aesthetic results. The technique avoids visible scars on the cheek and does not require insertion through a potential contaminated area such as nasal mucosa.

Orbitomalar Suspension During High SMAS Facelift

Traditional facelift techniques have some limitations: superficial musculo-aponeurotic system (SMAS) dissection may be incomplete in the superior medial orbitomalar region, and the centrofacial approach does not incorporate SMAS elevation. Orbitomalar suspension (OMS) during high SMAS facelift combines the best of other techniques and may enhance aesthetic results and improve blending of the eyelid-cheek junction while minimizing the risk of lower eyelid ectropion. The authors examine the efficacy and complication rates of the OMS procedure. Sixty patients underwent OMS as a primary component of high SMAS facelift and lower blepharoplasty. The technique is designed to accomplish superior-medial repositioning of the cheek while stabilizing lower eyelid position, reducing the risk of postoperative ectropion. Minor complications related to the OMS procedure occurred in three patients, all of whom had palpable and slightly visible Vicryl knots on one or both lateral upper eyelids. In one patient, the right side was reopened with a limited incision and the knot was removed. One case of lower eyelid malposition occurred and required revision. This patient presented on day three with unilateral left ectropion (2 mm), but the broken suture was easily replaced under local anesthesia, and the patient had no further ectropion. Two patients had transient lower eyelid malposition, which resolved within four weeks of surgery after gentle massage and lateral eyelid support with steri-strips. Two patients with prominent eyes and inferior orbital rim recession (negative vector) were not fully corrected; however, their lid position was no worse than the preoperative position and curvature. OMS during high SMAS facelift complements the deeper plane by adding a medial and superior vector of elevation to the cheek. Blending of the lower eyelid-cheek junction is accomplished with little risk of lower eyelid malposition.

Total Ambulatory SMAS Lift by Hidden Minimal Incisions Part 1: Temporal SMAS Lift

Since Mitz and Peyronie described the superficial musculoaponeurotic system (SMAS) in 1976 the SMAS facelift has become common. The author's idea to lift the whole SMAS in a temporal direction is realized in the surgical technique termed temporal SMAS lift by minimal hidden incisions. This ambulatory SMAS lift is helpful for changing the mask of tragedy appearance into one resembling the mask of comedy in surgery performed for beautification, soft-tissue laxity, early facial ptosis, and revision facelifts.

Refinements in face lifting: enhanced facial contour using vicryl mesh incorporated into SMAS fixation.

As we have gained experience with the extended superficial musculoaponeurotic system (SMAS) technique in face lifting, refinements in our procedure have led to increased consistency in results. The important factors that have led to our technical modifications include the following: (1) the significance of the retaining ligaments of the midface, which determine the degree of surgical dissection required for both skin and SMAS in rhytidectomy; (2) the changes in facial shape that occur with aging, secondary to the descent of facial fat; (3) the possibility of modifying facial shape through the repositioning of facial fat in an extended SMAS face lift; (4) the improved longevity of result to be obtained by incorporating Vicryl mesh into SMAS fixation; (5) the artistic nuances of incision design that help to minimize scar perceptibility. Understanding these factors enables surgeons to use the extended SMAS technique successfully with more challenging cases, enhancing facial appearance while minimizing signs that the patient has undergone a surgical procedure.