Superficial Musculoaponeurotic System Flap Research Articles

The Detailed Anatomy of the Deep Plane of the Face and Neck with Current Nomenclature.

The fundamental goal of modern face and neck lifting is to enhance and restore a more youthful facial appearance by addressing soft tissue descent. There are variations in described facelift technique including superficial musculoaponeurotic system (SMAS) flaps, composite flaps, deep plane, skin flaps, and subperiosteal facelifts, among others. The term "deep plane rhytidectomy" was originally described by Hamra. This term has since been linked with facelift surgery with recent advances including incision placement, treatments of SMAS-platysma complex, and mastoid crevasse among others. In the lead authors' experience, using deep plane techniques have demonstrated superior facial surgical rejuvenation results with less dependence on ancillary measures such as fat grafting or implantation for midface volumization. In order to successfully perform any face or neck lift, it is key to understand the relationship of the skin, the fat compartments, and the ligamentous attachments. This chapter details the anatomy of the deep plane of the face and neck and explains some nuances as it relates to surgical lifting. We also describe recent anatomical revelations of the mandibular ligament and its management in deep plane face lifting. In this chapter, given this opportunity to share personal experiences and preferences, the authors hope to describe relevant anatomy for the deep plane and provide some clarity on the merits of deep plane face and neck lift technique.

Using a Novel Method to Quantify and Confirm the Variable Vertical Vector of the Deep Plane Facelift.

Background: In deep plane rhytidectomy, it is accepted that a more vertical vector will lead to a more natural rejuvenated look than a horizontal vector of pull. Objective: Among patients undergoing deep plane rhytidectomy, can skin angle measurements designed by the authors be used as a proxy for vector of tension to confirm a vertical vector? Methods: Case series measuring the rhytidectomy vector of pull for a series of patients performed by a single surgeon. Results were compared between the vectors of the pre- and postauricular flaps as well as comparing the vector of pull in male versus female patients, patients undergoing facelift alone versus in conjunction with other rejuvenation procedures, and between primary versus revision rhytidectomy patients. Results: Patient characteristics: Average age 64.4 (range 47-79), predominantly female (26/28, 92.9%), primary rhytidectomy (24/28, 85.7%), with concomitant brow lift (12/28, 42.9%). Results reveal a more vertical than horizontal vector of pull on both the pre- and postauricular superficial musculoaponeurotic system flaps with the vector of the anterior flap being more vertical than that of the posterior flap. Conclusion: Utilizing a novel proxy measurement, the vector of pull of the deep plane facelift was more vertical than horizontal.

Cutis Laxa and the Value of Rhytidectomy: 4 Patients and Years of Follow-Up.

The modalities of the esthetic treatment of cutis laxa (CL) patients have rarely been discussed. Here, the authors present 4 CL rhytidectomy cases. The surgery method was designed based on the traditional full-incision face-lift technique combined with lamellar superficial musculoaponeurotic system flap elevation and plication. Temporal, buccal, mandibular, and cervical regions were targeted. The shortest follow-up was 30 months, and the longest was 72. The results were assessed by subjective satisfaction and third-party photo evaluation. The subjective satisfaction was graded into worse than preoperation, no improvement, slight improvement, moderate improvement, and obvious improvement. The satisfaction rate was the sum of moderate and obvious improvement. Eighteen uncorrelated professionals participated in the third-party photo evaluation, in which the preoperative and follow-up photos were presented, and frontal, temporal, mid-face (including jowl), and cervical (including mandibular line) regions were evaluated as improved or nonimproved. The outcome of the subjective satisfaction was graded as no improvement (2/12, 16.7%), slight improvement (3/12, 25%), moderate improvement (4/12, 33.3%), and obvious improvement (3/12, 25%). The satisfaction rate was 58.3%, most investigators denied the frontal and temporal region improvement, 60% observed mid-face improvement, and 80% noticed cervical improvement. Most patients and their parents had positive attitudes towards the treatment results; however, the full expectation was not achieved. The cervical region maintained the best improvement after our treatment and the mid-face ranked second. This surgery method conduces to the esthetic requirement of CL patients; however, skin laxity remains a challenge.

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.

Lipofilling after total parotidectomy: a useful option to prevent functional and aesthetic sequelae

Parotidectomy is the main treatment for parotid tumours, but its functional and aesthetic sequelae can be very disturbing for patients. 15 patients underwent total conservative parotidectomy, harvesting of a superficial musculoaponeurotic system (SMAS) flap and lipofilling between May 2014 and June 2020 for a benign parotid tumour. Aesthetic, functional sequelae and cosmetic results were assessed with the House-Brackmann scale, Luna-Ortiz's classification and a semiquantitative questionnaire. Lipofilling resorption was analysed by maxillofacial and neck MRI imaging at 2 years after surgery. The results were compared to a group of 21 patients who underwent total parotidectomy without harvesting a SMAS flap and lipofilling. No complications were observed. No facial defects were seen during follow-up. Post-operative MRI showed fat resorption was less than 20% in 12 patients and from 20 to 30% in 3 patients. Cosmetic satisfaction was 100% in all cases. Only 1 patient (6%) complained of Frey's syndrome. Lipofilling is an excellent solution considering its efficacy, safety, simplicity, duration over time and economic costs. Donor site invasiveness is minimal, and reintervention is always possible. Face-lift incision and SMAS flap can improve aesthetic results and minimise the disfiguring impact of the surgical scar.

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.

Parotid Surgery With Concurrent Bilateral Rhytidectomy

Facial reconstruction after parotid surgery can present an aesthetic challenge. This case series describes an asymmetric cervicofacial rhytidectomy technique at the time of parotid surgery to achieve defect closure as well as volume augmentation of the postablative deformity. While unilateral superficial musculoaponeurotic system (SMAS) flaps after parotid tumor extirpation have been described many times, this is the first reported case series of parotid tumor resection with concurrent bilateral cervicofacial rhytidectomy. This series consists of two adult females with unilateral facial swelling who also desired facial rejuvenation surgery. They separately presented to the University of Texas Southwestern Maxillofacial Surgery team and proceeded to have unilateral parotid tumor removal with concurrent bilateral cervicofacial rhytidectomy. To give context to this case series, the authors also searched the PubMed, Scopus, and Google Scholar databases to look for previously reported similar cases. The authors were able to address the patients’ functional as well as aesthetic concerns with a single surgery in a safe manner. Ipsilateral to the tumor resection, there was a sizeable loss in volume in both cases. Therefore, a vascularized SMAS flap was imbricated to provide volume, while a selective SMAS removal and plication was used on the contralateral side to achieve symmetric volume bilaterally. A comprehensive literature search demonstrated one previous report of concurrent bilateral cervicofacial rhytidectomy with parotid tumor extirpation. Despite the prevalence of utilizing a rhytidectomy incision for parotid surgery, there is a dearth of literature describing concurrent bilateral cervicofacial rhytidectomy with parotid tumor extirpation. Functionally, it has been shown to decrease the incidence of gustatory sweating on the side of reconstruction. Aesthetically, the surgeon is not only re-establishing the volume by augmenting the ablative defect, but also creating a symmetrical postoperative appearance by performing a reductive rhytidectomy on the contralateral side. Utilizing an asymmetric bilateral cervicofacial rhytidectomy at the time of parotid surgery can be an efficient technique for aesthetically reconstructing a patient with a parotid mass. It should be considered in patients with benign parotid disease who have the desire for facial rejuvenation surgery.

Modified facelift incision and superficial musculoaponeurotic system flap in parotid malignancy: a retrospective study and review of the literature

BackgroundData reporting the use of modified facelift incision (MFI) approach with or without superficial musculoaponeurotic system (SMAS) reconstruction in parotid malignancy are limited. To enhance the limited knowledge in this subject, the authors of the current study report quality data of MFI in patients with parotid malignancy with or without SMAS reconstruction.MethodsWe performed a retrospective review of parotid malignancy patients treated with the MFI over a 5-year period (2015–2019) in the 1st ENT University Department, University of Athens, Greece.ResultsWe identified five patients with parotid malignancy. We performed MFI parotidectomy in 5/5 patients and SMAS reconstruction in 2/5 patients. All tumors were classified as T1N0M0. After a mean follow-up of 43.6 months (minimum, 36; maximum, 55), we noted no recurrence. The patients reported no Frey’s syndrome.ConclusionsThe authors of the current study suggest consideration of the MFI approach in parotid malignancy. A MFI approach should at least favor small parotid tumors without neck metastatic disease (T1cN0). Surgeons could also address larger tumors with a MFI approach. Surgeons should reconstruct the parotid lodge with a SMAS advancement flap in tumors not in proximity with the SMAS.

A modified V-shaped incision combined with superficial musculo-aponeurotic system flap for parotidectomy

Background: V-shaped incision (VSI) for parotidectomy had been introduced for cosmetic purpose. Despite having aesthetic superiority, it required excessive retraction or an additional hairline incision for adequate surgical exposure. To overcome these problems, we conceptualized a modified VSI approach combined with a separate superficial musculo-aponeurotic system flap.Aims: This study aimed to propose this approach and evaluate its technical feasibility and efficacy for excision of parotid tumors.Materials and methods: This is a prospective, nonrandomized study involving 74 patients with small-to-medium (<4 cm), benign parotid tumors located superficially. The patients were divided into two groups based on the incision techniques used: modified VSI and modified Blair incision (MBI). The clinical outcomes of both approaches for parotidectomy were analyzed.Results: Thirty-four patients underwent modified VSI approach, while 40 underwent MBI. All parotidectomies with modified VSI were successfully completed without any further incision, and no facial nerve injury or intraoperative tumor rupture complication was reported. There were no significant differences in the complications between both approaches, such as hematoma, infection, wound dehiscence, skin necrosis, sialocele, or sensory disturbance. The modified VSI group showed better cosmetic satisfaction results than did the MBI group (9.2 and 7.8, respectively; p < .001).Conclusions and significance: The modified VSI approach is safe and feasible for small-to-medium benign parotid tumors. This approach could be a possible option for patients with a high cosmetic demand.Level of Evidence: 4.Study design: Prospective pilot study.

Preserving Orbicularis Branches of the Zygomatic Nerve with the Orbicularis Oculi Muscle-Superficial Musculoaponeurotic System Flap Complex in Facelift Surgery.

Summary:The orbicularis oculi muscle (OOM) is sometimes incorporated with the superficial musculoaponeurotic system (SMAS) flap to provide a stronger flap. While elevating the OOM flap, it is important to avoid injury to the orbicularis branches of the zygomatic nerve. When the orbicularis branches of the zygomatic nerve are identified during the OOM-SMAS flap elevation, a transverse OOM flap was created to preserve the nerve. Postoperative follow-up was 12 months. There was no functional impairment of the OOM in the follow-up period. There are anatomical variations of the orbicularis branches of the zygomatic nerve. When it is identified, a transverse OOM flap incorporating it can be raised to avoid inadvertent injury. Using this method, good results were achieved with virtually no complications.

The Utility of Superficial Musculoaponeurotic System Flaps in Facelift Procedures.

Facelift techniques widely vary with known individual surgeon modifications of and preference for particular techniques. This article provides an overview of the history of the superficial musculoaponeurotic system (SMAS), the changes of aging related to the soft tissues of the face, and the history of facelift procedures, including techniques to address the SMAS. In addition, a description of past studies and literature analyzing techniques of facelift procedures, safety of interventions involving the SMAS, low, extended, and high SMAS techniques, and evaluations of patient satisfaction with facelift outcomes including use of the FACE-Q are discussed. After review of the existing literature, a knowledge of the process of aging, and its effect on facial soft tissues, there is data to support SMAS flaps as a safe, effective, and logical means to handle the SMAS in facelifts. There is a paucity of the literature directly comparing differing techniques, particularly regarding SMAS flaps, leading to a challenging review but significant opportunity for additional study.

Assessment of functional outcome after parotidectomy reconstruction

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Total or superficial parotidectomy, when a reconstructive technique is not used, usually leads to Frey’s syndrome, preauricular and retromandibular depression. These together with the scar from a classic or modified Blair incision limit the final aesthetic outcome. The superiorly based sternocleidomastoid muscle (SCM) flap or superficial musculo-aponeurotic system (SMAS) flap can be used for reconstruction of the defect to achieve better facial contour restoration. The aim and objective of the study was to evaluate the functional and cosmetic outcome of patients after reconstruction in parotid surgeries.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; This study was done in the department of Otorhinolaryngology &amp;amp; Head-Neck Surgery. Total number of patients with parotid tumours were 24 in each group namely- Group A: Patients undergoing parotid surgery without reconstruction. Group B: Patients undergoing parotid surgery with reconstruction using superiorly based sternocleidomastoid muscle flap. All patients were followed and analyzed on 6 weeks, 6 months and 1 year postoperatively on the basis of patient’s satisfaction, cosmesis, subjective Frey’s syndrome, retromandibular and pre-auricular depression using visual analogue scale. &lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; In Group A, subjective Frey’s syndrome was present in 8.3% patients from 6 month to 1 year. In contrast, in Group B, it remain absent in all patients at all periods. In Group A, preauricular depression was present in 79.2% patients in immediate postop and 95.8% patients from 6 week to 1 year. In contrast, in Group B, it was present in only 4.2% patients at all periods. In Group A, retromandibular depression was present in 70.8% patients while in Group B, it was absent in all patients.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; The superiorly based SCM flap for reconstruction of defect following superficial or total parotidectomy improves the final outcome in terms of the facial deformity (pre-auricular, retro-auricular depression) and lowers the incidence of Frey’s syndrome.&lt;/p&gt;

Reconstruction of parotidectomy and lateral skull base defects

The purpose of this review is to summarize the options for reconstruction of parotid and lateral skull base defects based on the size and functional requirements of the defect. Free grafts with dermal fat or acellular human dermis, superficial musculoaponeurotic system flaps, and sternocleidomastoid flaps have been successful in preventing Frey's syndrome and restoring facial contour defects after superficial and total parotidectomy. Lateral skull base resections often require reconstruction with pedicled or free flaps to restore extensive soft tissue and dural defects. Supraclavicular artery island flaps and submental flaps have been recently been gaining popularity for use for these purposes. Free tissue transfer remains the best reconstructive option for repair of large soft tissue and/or dural defects. The most reliable free flap for lateral skull base reconstruction is the anterolateral thigh flap, which is highly versatile because of its large skin paddle and potential for harvest with varying amounts of fascial and muscle tissue. Here we will summarize the most appropriate and widely used reconstructive options for parotid and lateral skull base defects of various sizes, discussing the most recent evidence pertaining to each technique along with advantages and limitations of each reconstructive strategy.

The Effects of Superficial Musculoaponeurotic System Flap on the Development of Frey's Syndrome and Cosmetic Outcomes After Superficial Parotidectomy.

To investigate the outcomes of superficial musculoaponeurotic system (SMAS) flap and classic techniques in superficial parotidectomy in terms of Frey's syndrome (FS) and cosmetic satisfaction. In this study, a retrospective chart review of patients that underwent superficial parotidectomy was performed. These patients were divided into two subgroups: group 1 included patients in which the SMAS flap was harvested and group 2 comprised the remaining patients on whom classic superficial parotidectomy was performed. All the patients were evaluated clinically and with Minor's starch-iodine test for FS. For the evaluation of the cosmetic results, the patient's satisfaction was queried according to the incision scar and surgical field skin retraction/facial symmetry. Both groups were compared in terms of complications and numbness of surgical area. Fifty-five patients (31 male and 24 female) with a mean age of 50.19 years were included in the study. Thirty-two patients were in group 1 and 23 in group 2. Thirteen patients (23.7%) described as having FS and six of them were in group 1, while seven were in group 2. Minor's starch-iodine test was positive in nine patients in group 1 (28.1%) and six patients in group 2 (26.1%) (p=1.000). With regard to cosmetic satisfaction, eight patients (25%) stated mild discomfort from the incision scar and two patients (6.3%) stated cosmetic dissatisfaction for facial asymmetry in group 1. In group 2 for the same factors the number of patients were 11 (47.8%) and 2 two (8.7%), respectively (p=0.027). There were no statistically significant differences in means of complication and numbness (p>0.05). According to our study results, there was no superiority between both the groups in terms of FS and incision scar satisfaction. We determined that there was a significant benefit of SMAS flap application in the prevention of volume loss and surgical area retraction.

The superficial musculoaponeurotic system flap in the prevention of Frey syndrome: A meta-analysis.

Evaluate the difference of the incidence in clinical Frey syndrome in studies comparing classical parotidectomy and parotidectomy with superficial musculoaponeurotic system (SMAS) flap elevation and suturing through meta-analysis methodology. Meta-analysis of controlled studies with and without SMAS flap. Database search with the following key word combination: "Frey syndrome" and "SMAS." parotidectomy, SMAS flap and control groups, minimal follow-up of 1 year. The outcome was the presence of clinical Frey syndrome. Eleven studies, mostly retrospective and not randomized. According to the fixed-effect model, SMAS technique is associated with a decrease of clinical Frey syndrome with an odds ratio (OR) of 0.42 (confidence interval [CI] 0.32-0.56). With the random-effect model, the difference remains significant (P = 0.006) with an OR of 0.25 (CI 0.09-0.66). The heterogeneity index I(2) is very high (85%). The use of SMAS flap and suturing is associated with a decreased incidence of Frey syndrome. Laryngoscope, 126:1581-1584, 2016.

Modified facelift approach combined with a superficial musculoaponeurotic system flap in the treatment of benign parotid tumors

The purpose of this study was to investigate the adequacy of a modified facelift incision combined with an SMAS flap for the resection of benign parotid lesions in terms of cosmesis and incidence of Frey's syndrome. A hundred patients who underwent superficial parotidectomy were divided into 2 groups according to approach: Blair incision (57 cases) and modified facelift incision (43 cases). In the latter group, 36 patients were reconstructed with a superficial musculoaponeurotic system (SMAS) flap. During follow-up, patients were asked to rate their satisfaction with their postoperative appearance using a 1 to 3 scale. Clinical Frey's syndrome was present in 8.5% of patients with SMAS flap, and in 19% patients without SMAS flap (p = 0.16). The average cosmetic outcome score for patients who underwent a modified facelift approach combined with an SMAS flap was 2.87, whereas patients whose tumors were approached through a Blair incision reported a lower score of 2.1 (p < 0.005). A modified facelift incision combined with an SMAS flap improved the cosmetic appearance of patients who underwent extrafacial or superficial parotidectomy. In addition, this flap seems to reduce the occurrence of Frey's syndrome.

Component approach to the temporomandibular joint and coronoid process.

Reconstruction of the temporomandibular joint (TMJ) region is challenging. The conventional direct preauricular incision permits only limited access to the TMJ and surrounding structures, therefore risking injury to the facial nerve during retraction. The ideal approach allows sufficient exposure, preservation of underlying neurovascular structures, and achieves an optimal aesthetic outcome. We describe a preauricular posttragal incision with a superficial musculoaponeurotic system flap to allow wide exposure of the zygomatic arch, TMJ, condyle, and coronoid process. We postulate that this approach improves access, lessens the amount of retraction required, and creates a more inconspicuous scar.

Biplanar superficial musculoaponeurotic system imbrication rhytidectomy.

Rhytidectomy techniques have evolved significantly since the procedure's introduction in the early 20th century. Significant advancements in rhytidectomy techniques occurred in the 1960s and 1970s with the description of the subfascial rhytidectomy, the identification of the superficial musculoaponeurotic system (SMAS), and development of the SMAS flap. The incorporation of fascial undermining and suspension techniques have significantly improved the longevity and natural appearance of the facelift operation. More aggressive techniques including subperiosteal, composite, and deep plane techniques have been developed in the pursuit of the perfect facelift procedure. On the basis of over 25 years of clinical and surgical experience, a biplane SMAS imbrication rhytidectomy provides a natural, unstretched, and refreshed appearance resulting in high patient satisfaction. This article will present a detailed description of the rationale, technique, and nuances of the biplanar SMAS imbrication rhytidectomy. While the management of the platysma may vary depending on individual patient characteristics, the extent of subcutaneous, sub-SMAS, and neck dissection employed using the biplanar SMAS imbrication rhytidectomy minimizes patient complications and allows a relatively rapid recovery.

Reconstructive Techniques of the Parotid Region

The aim of our study was to evaluate and check (analyze and compare the results) the complications of patients with benign parotid disease reconstructed with the 3 reconstructive techniques used after the removal of benign tumors of the parotid gland treated at our institution. The reconstruction of this anatomical region may include the use of superficial musculoaponeurotic system (SMAS) flap, flap of sternocleidomastoid muscle, and temporoparietal fascia flap to prevent aesthetic and functional complications. We carried out a retrospective review of 224 patients operated on between February 2002 and March 2009 with benign primary parotid tumors. Extracapsular dissection or superficial parotidectomy was performed and then these patients were reconstructed with the 3 techniques that we used to apply at the Department of Maxillofacial Surgery in the University Federico 2 of Naples: the SMAS flap, flap of sternocleidomastoid muscle, and temporoparietal fascia flap. The statistical difference between the extracapsular dissection versus superficial parotidectomy and the statistical difference between the 3 types of flaps as concerns evaluated recurrence rate and complications were measured with the χ test. The chosen level of statistical significance was P less than 0.05. Out of the 224 enrolled patients, 103 were women and 121 men, with an average age of 54 years. After histopathological examination, 136 adenomas and 88 cystadenoma lymphomas were diagnosed. Enucleoresection was the surgical technique adopted in 169 cases while superficial parotidectomy was used in the remaining 55 cases. The reconstruction was performed with SMAS flap in 122 patients, with muscle flap SMC in 66 patients and temporoparietal fascia flap in 36 patients. Table 1 shows that no significant differences as concerns hematoma and wound infection were observed after extracapsular dissection and superficial parotidectomy(1.8% vs.1.8% [P > 0.05] and 1.8% vs. 5.5% [P > 0.05]). Transient facial nerve weakness, fistula, dip skin, Frey syndrome, spinal nerve injury, and facial paralysis were significantly more frequent after superficial parotidectomy than after extracapsular dissection (4.1% vs. 27.3% [P < 0.001], 1.8% vs. 10.9% [P < 0.001], 3% vs. 12.7% [P < 0.001], 0% vs. 5.5% [P < 0.001], 0% vs. 3.6% [P < 0.001], and 0% vs. 9.1% [P < 0.001], respectively). Table 3 shows that the presence of Frey syndrome is statistically significant in the first 2 comparisons, group I against group IV and group II against group V, respectively (P < 0.05 and P < 0.01). And in the first comparison between group I and IV, there was a statistically significant presence of transient facial nerve weakness (P < 0.001), fistula (P < 0.001), dip skin (P < 0.05), and facial paralysis (P < 0.001). In the second comparison between group II and group V besides the presence of Frey syndrome, there is also a statistically significant presence of transient facial nerve weakness (P < 0.05), skin depression (P < 0.05), accessory spinal nerve injury (P < 0. 01), and facial paralysis (P < 0.01). In the comparison between the third and the sixth group, there is a statistically significant presence of transient facial nerve weakness (P < 0.05), fistula (P < 0.01), and facial paralysis(P < 0.05). Extracapsular dissection showed similar effectiveness and fewer side effects than superficial parotidectomy, and the 3 reconstruction techniques used in this trial drastically reduce the occurrence of post-parotidectomy Frey syndrome and greatly reduce functional and aesthetic complications.

Modified Lateral SMASectomy

Sir: Recently, advances on facial anatomy have been significantly achieved by Rohrich and Pessa1 and Mendelson et al.2 For this reason, various face-lift techniques have evolved and been introduced into clinical practice.3,4 Although limited-incision face lifts are popular, conventional face lifts have their own indications for treatment of aging face with severe skin laxity. Recently, face lifts with lateral superficial musculoaponeurotic system (SMAS)-ectomy technique have gained prominence among plastic surgeons. The theoretical benefits of lateral SMASectomy for facial rejuvenation are a short recovery time, relatively simple operation, low incidence of complications such as tearing of the SMAS and potential facial nerve injury, vertical elevation and strong fixation of the SMAS, comparable outcome with extended SMAS technique, and a short scar because of limited incision. Because of these advantages, we think the original technique is a good option with regard to overall improvement of skin tightness and effacement of fine wrinkles. However, we are somewhat suspicious of the effect on midface ptosis. Thus, following the original lateral SMASectomy described by Daniel Baker in 1992, various modified techniques have been introduced.5 We also adopted our own modified lateral SMASectomy design. The procedure was performed under local anesthesia with intravenous sedation. After access skin incision, dissection extends across the zygoma to release the zygomatic ligaments and masseteric cutaneous ligaments. We do not dissect further anteriorly. Then, we designed a trapezoid SMAS flap. The superior border of the incision was approximately at the level of the zygomatic arch and the inferior border was approximately 4 to 5 cm below the jaw line. A representative design is shown in Figure 1.Fig. 1: Intraoperative design of the modified lateral flap.Over a 2-year period, the patients underwent modified lateral SMASectomy. The treatment outcomes were evaluated both subjectively and objectively. All but four patients [33 of 37 (89.1 percent)] were satisfied with the outcomes after the surgical procedure. Consensus ratings by the two independent plastic surgeons found that objective outcomes were divided among excellent, good, and fair. None of the outcomes was rated as no change or worse. The postoperative course was uneventful, with the exception of five patients (13.5 percent) who presented with skin slough, hypertrophic scar, and hematoma. We think that our modified technique can be considered as another option that yields a better effect on midface ptosis, jowl, and jaw line and more powerful effacement of nasolabial folds. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. Tae Hwan Park, M.D. Jin Hyuk Park, M.D. Kwi Whan Whang, M.D., Ph.D. Research Department Miz Aesthetic Surgery Clinic Seoul, Republic of Korea