Superficial Musculoaponeurotic System Rhytidectomy Research Articles

Subperiosteal Midface Lift with Sub–Superficial Musculoaponeurotic System Rhytidectomy

The subperiosteal midface lift is a powerful tool that allows the surgeon to reposition the SOOF and malar fat pad in a vertical direction. Additionally, it significantly softens deep nasolabial folds. Its effect, however, is minimal with regards to addressing the jowl, jawline, gonial angle and cervicomental angle. Combining the subperiosteal midface lift with an extended sub-SMAS rhytidectomy addresses the pre-jowl sulcus by releasing the mandibular ligament. The jawline and gonial angle become more defined with the transposition and suspension of the SMAS flap. The SMAS transposition flap along with the suspension of the platysma flap to the mastoid fascia support the submandibular glands and deepen the cervicomental angle. These two approaches are valuable additions to the surgeons armamentarium and can yield excellent results in carefully selected patients.

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.

Depth Transitions of the Frontal Branch of the Facial Nerve: Implications in SMAS rhytidectomy

BackgroundAnatomy of the frontal branch of the facial nerve relative to the zygomatic arch and the superficial musculoaponeurotic system (SMAS) has been well described. The variability centers on the location where the frontal branch traverses from a deeper to more superficial plane in the SMAS. The goal of this study is to examine the depth transition of the frontal branch of the facial nerve relative to the zygomatic arch with hopes of pinpointing a caution zone for dissection to avoid nerve injury. MethodsThe frontal branch of the facial nerve was dissected in 36 hemifacial fresh cadaver specimens. Pitanguy's line, the zygomatic arch, and temporal crest were marked. Measurements were taken from the zygomatic arch to the location where the frontal branch pierced the temporoparietal fascia. Locations of the superficial temporal artery (STA), the frontal branch cross relative to the lateral orbital rim and frontalis muscle were also measured. ResultsIn 94.4% (n = 36) of the specimens, the frontal branch was found to transition to an intra-SMAS plane approximately 9.6 mm above the zygomatic arch. In all specimens, the frontal branch transitioned to an intra-SMAS plane approximately 12.2 mm posterior to Pitanguy's line. ConclusionsThis study describes a surgical “caution zone” centered on a point 9.6 mm above the arch and 12.2 mm posterior to Pitanguy's line, and related to the anterior branch of the STA. We hope this anatomical detail will help to decrease the likelihood of intraoperative injury to the frontal branch of the facial nerve.

Long-term Analysis of Lip Augmentation With Superficial Musculoaponeurotic System (SMAS) Tissue Transfer Following Biplanar Extended SMAS Rhytidectomy.

To our knowledge, long-term, objective results of lip augmentation using superficial musculoaponeurotic system (SMAS) tissue transfer beyond 1 year have not been previously described. To evaluate the efficacy, longevity, and safety of lip augmentation using SMAS tissue transfer. A retrospective single-blind cohort study was designed to evaluate all patients who underwent surgical lip augmentation using SMAS following rhytidectomy between January 1, 2000, and November, 16, 2015, at a private facial plastic surgery practice in Birmingham, Alabama. Preoperative photographs of each patient served as controls and were compared with postoperative photographs at 3 months, 1 year, and 5 years after lip augmentation. A total of 104 images (from 26 individual patients) were reviewed by 12 blinded observers using a validated lip augmentation grading scale. Lip augmentation using SMAS. Median lip volumes of all patients at each postoperative interval (3 months, 1 year, and 5 years) compared with preoperative lip volumes. Secondary outcome measures included postoperative complications. A total of 423 patients were identified who underwent surgical lip augmentation using SMAS. Sixty patients with approximately 5 years or more of postoperative photographs were reviewed for complications. Twenty-six patients had 3-month, 1-year, and 5-year postoperative follow-up photographs and were included in the photographic evaluation. The mean age of these patients at the time of surgery was 54.6 years (range, 41.2-80.6 years. Fifty-nine of the 60 patients (98.3%) were female. Two of 60 patients (3.3%) with 5 years or more of postoperative follow-up developed complications requiring intervention. Both the superior lip and the inferior lip showed statistically significant increases in volume at 3 months, 1 year, and 5 years (P ≤ .004 for the superior lip after 5 years; P ≤ .001 for all other comparisons) after SMAS lip augmentation. The greatest median increase was observed in the superior lip at 3 months, while the smallest median increase was observed for the inferior lip at 5 years. The degree of increase in median volume seemed to weaken slightly over time, but remained statistically significant even at 5 years. SMAS lip augmentation is an effective and safe method for lip augmentation that can yield natural, long-lasting results with minimal risk. The degree of augmentation tends to fade slightly over time, but remains significant for at least 5 years postoperatively. 3.

Endoscopically Assisted Triple-Suture Midface Lift: A Refined Cable-Suture Technique

Superior repositioning of ptotic malar fat pads in an aging face is considered a key element in midface rejuvenation [2, 4, 5]. Several surgical techniques have been developed to achieve this goal, but many remain technically challenging or are associated with increased patient morbidity [6, 7]. The unique anatomy of the malar fat pad, loosely attached to the superficial musculoaponeurotic system (SMAS), makes elevation of the malar fat pads via traditional methods of SMAS rhytidectomy less than optimal [1, 2]. The principle of transcutaneous suspension of malar fat pads with cable sutures was introduced in 2002 [7]. The cable-suture technique can provide both restoration of volume and optimal repositioning of fat pads. Based on this, we developed the endoscopically assisted triple-suture midface lift (‘‘3S’’ midface lift) technique to enhance the midface lift through three sets of suspension sutures, all anchored to the deep temporal fascia: (set 1) transcutaneous suspension cable suture around the nasolabial fold, (set 2) suspension suture on the apex of the malar fat pad, and (set 3) temporal scalp dermal suspension suture. Preoperative markings are drawn with the patient sitting. The nasolabial crease is marked, and a point is marked on the midpoint along a line 5 mm lateral and parallel to the nasolabial crease. This is where a stab incision will be made for the insertion of a cable suture. The vector along which the cable suture will be pulled is perpendicular to the nasolabial crease. Another point 20 mm below the lateral canthus is marked, indicating where the suspension suture on the apex of malar fat pad will be placed. This point is similar to Tonnard’s point [8, 9] The temporal scalp incision is about 20 mm behind the hairline. This procedure can be performed with the patient under local or general anesthesia depending on what other accompanying procedures are being performed simultaneously. The temporal incision can be extended caudally to join the preauricular incision of open rhytidectomy or be a standard temporal working port for an endoscopic forehead lift. The dissection is performed with the help of a 3-mm 30 endoscope on the plane between the superficial and deep temporal fascia. The dissection is carried gradually into the midface between the suborbicularis oculi fat and the orbicularis oculi muscle [3]. After the midface is entered, further dissection is performed bluntly into the cheek region. Figure 1 shows the extent of the dissection. The cable suture is inserted through the stab wound lateral to the nasolabial crease using the method described by Sasaki and Cohen [7]. The thread of the cable suture is passed through to the temporal incision. Under direct vision by the endoscope, a hemostat is inserted to grasp the apex of the malar fat pad at the previously marked point below the lateral canthus. After confirmation of adequate malar fat pad movement, a 4-0 Prolene suture is passed through and also brought out through the temporal incision. Both the cable suture and the malar fat pad suture are anchored to the deep temporal fascia and tied with maximal tension. The medial edge of the temporal scalp wound then is deepithelialized to a width of about 3 mm. The deepithelialized portion is anchored to the deep temporal C.-C. Yu R. Tsai T.-C. Tung (&) Celebrity Cosmetic Center, 3F-1, 243, Sec. 1, Fu-Hsing S. Rd, Taipei City 10666, Taiwan e-mail: tung@celebritycosmetic.com

The Purse-String Reinforced SMASectomy Short Scar Facelift

Over the last two decades, short scar facelifts, often referred to as "mini" facelifts, have gained popularity. We use a purse-string reinforced (PRS) superficial musculoaponeurotic system rhytidectomy (SMASectomy) shortscar facelift that combines a SMASectomy in the vertical direction and suspension sutures in order to improve structural facial support. In the case of visible platysma bands and/or local fat deposition, liposuction (frequently followed by an anterior plastysmaplasty procedure) was added to correct features that are not consistently correctable using only a short scar facelift. This study retrospectively analyzes our experience with a new type of short scar facelift technique that combines both a superficial musculoaponeurotic system rhytidectomy (SMAS-ectomy) and suspension sutures with a thorough approach to the anterior surface of the neck. Over a period of three years, the PRS short scar facelift was performed in 137 patients with a mean age of 55 years (range 23-79 years). In almost half of the patients, the PRS short scar facelift was preceded by a separate treatment of the anterior neck contour by liposuction (67/137 patients; 49%). In two-thirds of these patients (42/67 patients), this liposuction was followed by an anterior plastymaplasty. Most patients (129/137; 94%) were satisfied or very satisfied with their results at the end of the follow-up period. Eight patients were not satisfied: five because of higher expectations, two because of insufficient improvement of the plastysma bands (which had not been treated by a plastysmaplasty procedure), and one because of the improper recognition of midface sagging (which had not been treated and was not properly discussed preoperatively). In the case of plastysma bands, platysmaplasty (n = 42) did improve the presence of these bands. There were no major complications in this series: 1 case had temporary neuropraxia of a buccal branch, which resolved after two months; two cases had hematoma, requiring evacuation on the outpatient clinic after one week; two cases with traction dimpling in the neck over the sternocleidomastoid region required late surgical revision; and one case had hypertrophic scarring in the preauricular area. The PRS technique is a short scar facelift technique that is both simple and safe. Complications are uncommon and usually minor. However, in the presence of platysma bands and/or local fat deposition, an anterior neck procedure-liposuction and/or anterior platysmaplasty-should be incorporated in order to optimize the results.

Deep-Plane Technique

Deep-Plane Technique

The extended SMAS facelift: identifying the lateral zygomaticus major muscle border using bony anatomic landmarks.

Extended superficial musculoaponeurotic system (SMAS) rhytidectomy has been advocated for improving nasolabial fold prominence. Extended subSMAS dissection requires release of the SMAS typically from the upper lateral border of the zygomaticus major muscle and continued dissection medial to this muscle. This maneuver releases the zygomatic retaining ligaments and achieves more effective mobilization and elevation of the ptotic malar soft tissues, resulting in more dramatic effacement of the nasolabial crease. Despite its presumed advantages, few reports have suggested greater risk of nerve injury with this technique compared with other limited sub-SMAS dissection techniques. Although the caudal extent of the zygomaticus muscle insertion to the modiolus of the mouth has been well delineated, the more cephalad origin has been vaguely defined. We attempted to define anatomic landmarks which could serve to more reliably identify the upper extent of the lateral zygomaticus major muscle border and more safely guide extended sub-SMAS dissections. Bilateral zygomaticus major muscles were identified in 13 cadaver heads with 4.0-power loupe magnification. Bony anatomic landmarks were identified that would predict the location of the lateral border of the zygomaticus major muscle. The upper extent of the lateral border of the zygomaticus major muscle was defined in relation to an oblique line extending from the mental protuberance to the notch defined at the most anterior-inferior aspect of the temporal fossa at the junction of the frontal process and temporal process of the zygomatic bone. The lateral border of the zygomaticus major muscle was observed 4.4 +/- 2.2 mm lateral and parallel to this line. More accurate prediction of the location of the upper extent of the lateral border of the zygomaticus major muscle using the above bony anatomic landmarks may limit nerve injury during SMAS dissections in extended SMAS rhytidectomy.

Minimal-incision endoscopic face-lift.

Ptosis of the midfacial tissues with resultant deepening of the melolabial folds, vertical lengthening of the lower eyelid, and depression of the oral commissure are generally only slightly improved with traditional superficial musculoaponeurotic system (SMAS) suspension or rhytidectomy techniques. Subperiosteal, deep plane, and composite rhytidectomies have evolved in an attempt to rejuvenate these areas. This article reviews a series of patients who underwent an endoscopic subperiosteal face-lift either as an isolated procedure or in conjunction with an SMAS rhytidectomy. Although all patients showed good initial improvement, patients with thin faces and well-defined facial bone structure maintained the best long-term result. Complications were minimal, with no permanent facial nerve injuries observed. The endoscopic subperiosteal face-lift is a useful technique as an isolated procedure or in conjunction with facial liposuction or SMAS suspension rhytidectomy. Arch Facial Plast Surg. 2000;2:274-278

SMAS Rhytidectomy versus Deep Plane Rhytidectomy: An Objective Comparison

Although there are a multitude of techniques currently used for performing face lifts, there is no general agreement as to which, if any, of these techniques is most effective. There may never be a definitive answer to this issue because of the highly subjective nature of aesthetics, variability among surgeons, differences in patient anatomy, and specific patient desires. In an attempt to evaluate face lift techniques objectively, this study compares the rate of patients undergoing a tuck procedure after traditional SMAS (superficial musculoaponeurotic system) rhytidectomy to that of patients after deep plane rhytidectomy. A retrospective chart review was performed on all patients who underwent a tuck procedure following a face lift by the senior author (Kamer) between July of 1990 and January of 1997. There were 634 patients who electively underwent either a SMAS or deep plane type of rhytidectomy during the 6.5-year period; 48 patients subsequently underwent tuck operations, and adequate information was available on 44 patients. Of these, 43 were women and the average age was 57 years. The overall tuck rate from July of 1990 to January of 1997 was 7.5 percent. The tuck rate following SMAS rhytidectomy was 11.4 percent, and that following deep plane rhytidectomy was 3.3 percent. Therefore, a tuck was required 71 percent less frequently after a deep plane lift than after a SMAS lift. This was found to be a statistically significant difference with a p value of .0001 (Fisher's exact test, 2-tail). If the assumption is made that the need for a tuck procedure implies a less than optimal face lift, then the data of this study suggest that the deep plane technique is more effective than the SMAS technique. (Plast. Reconstr. Surg. 102: 878, 1998.)