Superficial Musculoaponeurotic System Research Articles

Advanced Deep-Plane Rhytidectomy: Advantages for Neck Treatment and Volumization of the Midface.

The aged neck is the most common motivator for patients seeking facial rejuvenation. Unlike the deflated midface, surgical treatment is still the gold standard for optimal outcomes. It is our view that the majority etiology of both the aged neck and deflated midface is gravity's effects on the superficial soft tissue envelope, leading to soft tissue redundancy. It is also our view that the deep-plane rhytidectomy is supported by anatomy, embryology, and clinical evidence as the best methodology to treat soft tissue redundancy without producing the aesthetic and longevity issues associated with superficial musculoaponeurotic system techniques. As one of the early pioneers in deep-plane rhytidectomy, the lead author will define contemporary advances in deep-plane technique such as dissection entry point, flap design, and flap fixation concepts that allow aggressive approach to treating both the aged neck and deflated midface.

Microfocused Ultrasound in Regenerative Aesthetics: A Narrative Review on Mechanisms of Action and Clinical Outcomes.

Microfocused ultrasound with visualization (MFU-V) is widely used in aesthetic medicine for skin tightening and rejuvenation. However, its role in regenerative aesthetics and its precise mechanism of action are not fully understood. This narrative review aims to contextualize and articulate the mechanism of action of MFU-V, evaluate its role in regenerative aesthetics, and assess its effectiveness based on existing clinical, histological, and skin-mechanical studies. A comprehensive literature search was performed to collect and analyze studies on MFU's biological mechanisms, clinical outcomes, and impact on extracellular matrix (ECM) regeneration. The review integrates findings from clinical trials, histological analyses, and biomechanical assessments to provide a cohesive understanding of MFU-V's role in aesthetic medicine. MFU-V emits focused ultrasound energy that penetrates multiple skin layers and the superficial musculoaponeurotic system, creating localized thermal coagulation points. These points initiate biological responses that recruit fibroblasts and stimulate the production of new collagen and elastin fibers. Enhanced ECM protein synthesis leads to significant improvements in skin biomechanics and quality, reducing skin laxity and enhancing appearance. Clinical studies support these findings, showing improvements in skin firmness and texture following MFU-V treatment. Through analyzing the underlying biological mechanisms and the observable clinical outcomes, this narrative review sets the stage for a comprehensive understanding of the mechanism of action and role of MFU-V in regenerative aesthetics.

The application of basic SMAS rhytidectomy and comprehensive SMAS rhytidectomy.

Rhytidectomy has made great progress in the past 50 years, especially after the proposition of the concept of superficial musculoaponeurotic system (SMAS). Our previous research had classified SMAS rhytidectomy into basic SMAS rhytidectomy (B-SMAS) and comprehensive SMAS rhytidectomy (C-SMAS) according to whether the treatment of SMAS aponeurosis is combined with retaining ligament, fat pad, mimetic muscles, etc. The purpose of this paper is to compare the outcomes of the 2 methods. Through multicenter collaborative research, 21 cases of B-SMAS and 18 cases of C-SMAS were collected. Photographs were taken pre- and post-operation for each patient, and the facial width of the lateral canthus level (upper face), the alar base level (middle face), and the oral commissure level (lower face) were measured. We compared the statistics of upper, middle, and lower face pre- and post-B-SMAS and C-SMAS to assess the ramifications of each operation. We used preoperative measurements minus corresponding postoperative measurements of specific operation to assess which position would acquire superior improvements. We also recruited 3 professional plastic clinicians to rate the ramifications of specific positions and approaches after pre- and post-photo comparing. Through comprehensive analyzing, we compared the improvements between B-SMAS and C-SMAS to assess which method is more beneficial concerning facial rejuvenation. Both B-SMAS and C-SMAS would acquire optimal changing concerning facial width in middle and lower face after operation (P < .05). Two methods all harvested better width changing effects in middle and lower face than upper face (P < .05). However, C-SMAS acquired better effects in middle and lower face than B-SMAS (P < .05). Both B-SMAS and C-SMAS are beneficial to facial rejuvenation. The effects in middle and lower face are better than upper face. In addition, C-SMAS may be more effective than B-SMAS.

Manipulation of the Nasal Superficial Musculoaponeurotic System to Enhance Midvault and Supratip Contouring

Manipulation of the Nasal Superficial Musculoaponeurotic System to Enhance Midvault and Supratip Contouring

Vascular Perspectives of the Midfacial Superficial Musculoaponeurotic System.

Objectives: Presently, data on the vascularization of the superficial musculoaponeurotic system of the face (SMAS) are lacking. Thus, the present study aimed to provide new conclusive data about the topography, density, and relationship of the SMAS blood vessels with other components, namely, the fibrous connective tissue and muscles. Methods: The study included a control lot of 42 cases from the archive of the radiology department. In this group, nuclear magnetic resonance angiography (MRA) was performed in order to identify the main sources of vascular supply. In the second group, tissue samples were collected from the midfacial region of 45 patients from the Oro-Maxillo-Facial and Plastic and Reconstructive Surgery clinics of 'St. Spiridon' County Clinical Emergency Hospital, Iasi. These patients received surgery for excision of tumoral formations that did not involve SMAS components. These samples underwent micro-CT analysis, hematoxylin and eosin (HE) staining, as well as immunohistochemical (IHC) staining for collagen type III, muscle tissue, and the vascular endothelium. Results: We discovered the particular way in which the SMAS components interrelate with vascularization and the regional differences between them. We have discovered a new vascular network specific to the SMAS, highlighted by both the micro-CT technique and microscopy on slides with special IHC staining. Significant differences were observed in the topographic arrangement, density, and relationships of the microscopic vasculature across midfacial regions. IHC staining provided morphological and functional information about the structure and vascularization of SMAS. Conclusions: The MRA technique could not detect the structural blood vessels of the SMAS and other methods for their in vivo visualization must be sought. The blood vessels of the SMAS mainly follow the topography of the muscle fibers. From the SMAS layer where they are found, the distribution branches reach the stroma of the region and the hypoderm. Our data can contribute to the development of surgical techniques tailored to each individual patient, as well as the enhancement of methods for stimulating cutaneous angiogenesis, improving scarring in this region, and advancing biotissue engineering techniques.

A Systematic Review and Comparative Analysis of Reconstructive Rhytidectomy: Advantages, Disadvantages, and Patient Outcomes.

Reconstructive rhytidectomy, commonly known as facelift surgery, is a prominent cosmetic procedure aimed at rejuvenating facial appearance by addressing signs of aging. This paper critically evaluates the advantages and disadvantages of various surgical techniques involved in rhytidectomy, including the superficial musculoaponeurotic system (SMAS), deep plane facelift, and subperiosteal approaches. This systematic review of recent literature highlights key outcomes such as scar quality, postoperative pain management, and patient satisfaction. While the techniques demonstrate significant improvements in aesthetic results and patient quality of life, they also present risks including complications, dissatisfaction with outcomes, and the financial burden of surgery. Future directions indicate a trend toward minimally invasive approaches, integration of regenerative medicine, and personalized surgical planning, aiming to optimize results and minimize risks.

Anatomical Study of the Superficial Musculoaponeurotic System in Relation to the Zygomaticus Major.

The superficial musculoaponeurotic system (SMAS) is crucial for the structural integrity and dynamics of facial expressions and is a particularly important consideration during facelift surgeries. This study investigated the anatomical structure and continuity of the SMAS at the site where the zygomaticus major (Zmj) originates, which is where the SMAS extends from the lateral to the anterior aspects of the face. Knowledge of these aspects is crucial for understanding the mechanics of facial movements and also the aging process. Dissections of 66 specimens and histological analyses were used to explore the intricate relationships and attachments between the SMAS and facial muscles. The findings indicated that at the Zmj origin site, the SMAS-connected to the inferior margin of the orbicularis oculi-covered the superficial surface of the Zmj fibers. As it tracked downward, the SMAS was observed to split into two layers lateral to the Zmj fibers, enveloping them both superficially and deeply. Additionally, as the SMAS continued forward, it ceased to be distinctly visible in the buccal area. These results provide a deeper understanding of the complex layering and interconnectivity of the SMAS, which supports facial dynamics and structural integrity. This information could be particularly useful in surgical and aesthetic procedures in the midfacial area.

The Neo-Pitanguy Ligament: A Three-Flap Technique For Skin Tensioning.

Creating a stable, long-lasting supratip break continues to be a challenge, particularly in patients with moderate to severe skin thickness. Multiple techniques have been previously described to address this, including Pitanguy's ligament preservation, re-suturing, and cartilage frame alterations to increase the tip-to-septal angle differential. Each have noteworthy limitations. The senior author developed a novel technique which utilizes the native Pitanguy ligament augmented by two bilateral, medially-based superficial musculo-aponeurotic system (SMAS)/soft tissue flaps. This reduces supratip dead space, prevents tissue glide while controlling supratip/tip shape and position. Twenty-six (n=26) primary rhinoplasties in which the supratip and tip skin sleeve was of appropriate thickness were selected and followed for 1-year post operatively. The tri-laminar neo-Pitanguy ligament (NPL) technique was employed in all patients. Every patient maintained a varied degree of supratip break at an average follow up time of 14 months (range: 12-16 months). There was one revision requiring local anesthesia. No patients requested or were indicated for a return to the operating room. No cases of post-operative pollybeak deformity were observed. The power of this novel supratip control technique is multidimensional. It allows the surgeon to precisely control the location of supratip break, creating a broad based, diamond-shaped supratip depression. Tri-lamination with the use of the two SMAS/soft tissue flaps provides added strength, control, and long-term stability compared to simple suturing. Soft tissue tensioning above, around, and below the new tip complex prevents dorsal skin tissue glide and further secures the infratip/columella in appropriate position.

Update: Prevention and Treatment of Parotid/Submandibular Gland Fistula/Sialocele Following Rhytidectomy with Botulinum Toxin A.

Dissecting deep to the superficial musculoaponeurotic system, SMAS, a popular option for facelifts, has the potential for injury to the parotid gland leading to post operative sialoceles and fistulas. Similarly, deep plane procedures in the neck which include partial submandibular gland resection may lead to salivary gland leaks. We previously described the management of sialocele following rhytidectomy.1 Since then, administration of Botulinum toxin A has emerged as the primary treatment and prevention of this rare complication. The technique of administration and dosage of botulinum toxin in the treatment algorithm is not well-defined. We present a literature review and our current protocol of the most efficacious injection technique and dosing to prevent and treat injury to the parotid and submandibular glands.

Full SMAS: Endoscopy-Assisted Full Facial Rejuvenation.

Every region of the face may bear the signs of aging. Treating isolated areas without adequate anatomical knowledge can lead to incomplete or artificial-looking results and decrease patient satisfaction. The authors' "Full SMAS" technique for complete rejuvenation addresses the anatomical continuity of the superficial musculoaponeurotic system (SMAS)-platysma to the deep-plane suspension of the face. The aim of this study was to evaluate the contribution of endoscopic techniques to traditional facelift and neck lift procedures. Procedures treating from the frontal and temporal regions of the superior part of the face to its mid and lower parts, including the cervical region, were evaluated. Treatment of the 3 sub-SMAS layers of the face was performed using endoscopy for repositioning the frontal region and midface. This procedure involved frontal and zygomatic-masseter ligament release, open treatment of the lower subplatysmal section, and the complete release of the retaining ligaments of the face and approach to the jowl. One hundred sixty-one patients underwent the Full SMAS technique, leading to long-lasting results, low complication rates, and high patient satisfaction. The Full SMAS is a systematic technique that provides complete facial rejuvenation by combining an endoscopic approach for the temporal and midface regions with traditional open approaches for the lower face and neck. Treating the temporal and midface regions by minimally invasive techniques (endoscopy) reduces the possibility of permanent nerve injuries, provides smaller scars, and creates natural, long-lasting results.

Anatomical Trajectory of the Corrugator Supercilii Muscle in Koreans: Implications for Aesthetic and Clinical Practices.

Understanding the attachment patterns of the corrugator supercilii muscle (CS) is vital for treatments designed to improve facial symmetry and functionality. The aim of this research was to elucidate the anatomical trajectory and intricate relationships of the CS within the upper face and midface, specifically focusing on its connections with the frontalis (FT) and orbicularis oculi (OOc) muscles. The CS was examined in 41 specimens of embalmed adult Korean cadavers using microdissection, histological analyses, and microcomputed tomography, an in-depth exploration of its anatomical positioning and intricate interactions with adjacent muscles. Some lower fibers of the CS extended to the upper orbital part of the OOc in 59.5% of cases, while the CS interdigitated or blended exclusively with the FT in 40.5% of cases. The fibers of the CS demonstrated diverse extensions towards the upper face and midface, exhibiting varied trajectories and lengths. Additionally, lower fibers of the CS extended to significant anatomical landmarks such as the OOc, malaris muscle, and the superficial musculoaponeurotic system (SMAS). This study demonstrates that precise understanding of the CS and its relationship with the FT and OOc is crucial for optimizing invasive or non-invasive treatment like botulinum toxin injection, SMAS lifting and browplasty surgery. The extension of lower fibers of the CS to significant anatomical landmarks indicates complex interactions with adjacent facial structures, highlighting the necessity of detailed anatomical knowledge for clinical applications.

The U-SMASectomy Facelift.

Manipulation of the superficial musculoaponeurotic system (SMAS) has become a mainstay of face lifting procedures. Traditionally, the various surgical approaches to the SMAS have been classified as either "low" or "high" SMAS techniques, the former of which, while expeditious, have been criticized for suboptimal upper midface rejuvenation. High SMAS techniques, by contrast, are lauded for their ability to improve upper midface contours, but may carry increased surgical risk, particularly in the hands of less experienced aesthetic surgeons. Presented is the U-SMASectomy facelift (USL)- an imbricating approach to the SMAS that builds upon well-described low SMAS techniques with the addition of a malar flap of mobile-only SMAS for orbitomalar rejuvenation. This novel, hybrid technique harnesses the advantages of traditional low and high SMAS techniques while mitigating surgical risk. Of 61 USLs performed, a minor complication rate of 16.4% was observed. No major complications were observed. Mean follow-up was 371 days. The USL is thus a safe and powerful facial rejuvenation technique for both beginning surgeons with advanced aesthetic training, and well-versed aesthetic surgeons alike.

An Approach to Selection of Face-Lift Techniques for Different Types of Faces: An Analysis of 1000 Asian Patients Over 9 Years.

A face-lift or rhytidectomy is the procedure most directly associated with rejuvenation. There are several surgical techniques for face-lifts, but criteria for the selection of techniques, based on the patient's face shape, are lacking. In this study, we report on our experience with specific indication criteria for each technique and the consequent achievement of good outcomes. From 2015 to 2023, 1 surgeon performed face-lifts on 1000 patients. Three different superficial musculoaponeurotic system (SMAS) techniques (SMAS dissection, SMASectomy, and SMAS plication) were applied depending on the degree of sagging of the patient's lower face, lateral facial profile, and SMAS mobility and condition. Superficial musculoaponeurotic system dissection was considered for the improvement of a square face, sagging jowls, and marionette lines. Superficial musculoaponeurotic system plication was applied with patients with less sagging jowls and prominent zygoma with concave lateral facial profile. SMASectomy was applied with patients with convex lateral facial profiles or when the SMAS was too thin or damaged. Patient postoperative satisfaction was surveyed using the FACE-Q score 1 year post surgery. Most of the patients attained natural-looking and long-lasting aesthetic outcomes and exhibited high satisfaction. The patients indicated that they looked about 11.2 ± 5.2 years younger than their actual age after the surgery. The mean satisfaction scores for each facial feature were as follows: cheeks (91.1 ± 7.8), marionette lines (88.5 ± 13.6), lower face and jawline (92.5 ± 14.2), under chin (87.8 ± 15.1), and neck (86.2 ± 18.5). Complications such as facial nerve injury, infection, hematoma, and flap necrosis were very rare. Establishing criteria for the selection of face-lift surgical techniques based on the degree of lower face sagging, lateral facial profile, and SMAS mobility and condition led to good outcomes. These criteria can be used by physicians to determine the most effective face-lift surgery technique based on a patient's individual features, which may improve surgical outcomes.

The Evolution of My Extended SMAS-Biplanar Deep Plane Facelift to a Composite Tissue Deep Plane Face and Neck Lift: Similarities and Differences.

In this article, Dr. Stephen Perkins, a seasoned facial plastic surgeon, presents his refined techniques in facelift surgery developed over four decades of practice. His evolution from traditional methods to the current composite tissue deep plane facelift is elucidated. His composite tissue deep plane facelift involves meticulous dissection and repositioning of the superficial musculoaponeurotic system (SMAS) and platysma in the deep plane, as well as incorporating his innovative "Perkins' Kelly clamp anterior platysmaplasty." This technique, refined through years of experience, aims for natural, enduring results, crucially addressing patient concerns such as jowling and neck laxity. Long-term analysis reveals the advantages of Dr. Perkins' technique, particularly in achieving sustained cervicomental angle improvement for over a decade postoperatively. This article underscores the importance of understanding deep plane facelift techniques, distinguishing between different approaches, and tailoring surgical interventions to individual patient characteristics. Dr. Perkins' comprehensive approach, incorporating advancements in surgical technique and meticulous patient care protocols, exemplifies the goal of achieving natural, long-lasting facial rejuvenation.

Instrumental Analysis of Retaining Ligaments and Literature Review. What Can We Deduce?

Objective: This article aimed to review systematically the literature to better characterize retaining ligaments of the face and their changes correlated to facial aging. The authors have investigated the retaining ligament dimensions in 2 different cohorts of patients. Background: Osteocutaneous facial retaining ligaments play an important role in the aging face. With the advancement of techniques and technologies used in procedures of facial rejuvenation, several structures of the face must be highlighted to obtain clinical success as the facial retaining ligaments. It is known that classic characteristics of the aged face imply in the retaining ligaments, the intimate relationship of the ligaments with the cutaneous tissue can be modified by structural and functional changes. Methods: Sixty patients, divided into 2 different cohorts age correlated, have undergone soft tissue ultrasound echography to measure the dimensions (length and thickness) of 2 retaining ligaments (zygomatic cutaneous ligament and mandibular ligament). Results: No significant differences in age correlation have been found in the dimensions of the 2 major retaining ligaments of the face. Conclusion: Retaining ligaments do not undergo substantial time-correlated changes to absolve their retentive function, unlike other facial layers (bone and fat compartments). This observation suggests that retaining ligaments must be preserved during sub–superficial musculoaponeurotic system dissection in a facelift procedure.

Aging of Superficial Musculoaponeurotic System of the Face-Novel Biomarkers and Micro-CT Relevance of Facial Anti-Gravity Support.

The soft superficial tissues of the face are against gravity through an intricate network of ligaments and ligamentous attachments. The aim of this investigation is to delineate the relationship between the muscular, fibrous, and vascular components of the superficial musculoaponeurotic system of the face (SMAS) at the level of its periosteal fixation areas from advanced radiological and novel biomarkers' perspectives. These areas represent key points underlying skin aging and the longevity of restorative surgery results. Methods: This study was carried out on 37 surgical specimens, excised from patients admitted for surgery. On the excised specimens, we used special immunohistochemical techniques, such as markers for collagen type III, angiogenesis, vascular endothelium (I-CAM2) and muscle fibers (MYH2). We performed a micro-CT evaluation of these 37 specimens. Results: The results of this study showed different radiologic and IHC characteristics of the means of periosteal fixation of the SMAS. Evidence of morphohistological and radiological peculiarities of the retaining ligaments highlights new data for future functional studies of these structures. Our research must be continued with larger groups of subjects and through detailed methodological studies of vascular microperfusion and could represent an important new step in biotissue engineering and the customization of surgical techniques involving the sub-SMAS layers.

Modified Endaural Approach With a Peripheral Dissection of the Superficial Musculoaponeurotic System to Access the Temporomandibular Joint to Prevent Facial Nerve Injury.

The purpose of this study was to assess the effects of protecting the facial nerve with a modified endaural approach with a peripheral dissection of the superficial musculoaponeurotic system to access the temporomandibular joint which allows an excellent operative field of visualization, multiple surgical procedures of the temporomandibular joint, and general care which improves the immediate postoperative period, making this a less morbid surgery. This study included 33 patients (39 sides) who underwent surgical treatment for disorders of the temporomandibular joint from the years 2021 to 2023 at the maxillofacial department of the clinic "Colsanitas" located in Bogota, Colombia. Therapeutic results were evaluated by postoperative facial nerve injury, with the House-Brackman scale; every patient was examined for adequate facial musculature function immediately after surgery. Notably, zero patients presented facial nerve injury. These results imply that the modified endaural approach with a peripheral dissection of the superficial musculoaponeurotic system to access the temporomandibular joint reduces the incidence of facial nerve injuries, improves operative site exposure, and lowers the frequency of complications.

Discussion: The Superficial Musculoaponeurotic System: Does It Really Exist as an Anatomical Entity?

Discussion: The Superficial Musculoaponeurotic System: Does It Really Exist as an Anatomical Entity?

Advanced Deep-Plane Rhytidectomy: Advantages for Neck Treatment and Volumization of the Midface.

The aged neck is the most common motivator for patients seeking facial rejuvenation. Unlike the deflated midface, surgical treatment is still the gold standard for optimal outcomes. It is our view that the majority etiology of both the aged neck and deflated midface is gravity's effects on the superficial soft tissue envelope, leading to soft tissue redundancy. It is also our view that the deep-plane rhytidectomy is supported by anatomy, embryology, and clinical evidence as the best methodology to treat soft tissue redundancy without producing the aesthetic and longevity issues associated with superficial musculoaponeurotic system techniques. As one of the early pioneers in deep-plane rhytidectomy, the lead author will define contemporary advances in deep-plane technique such as dissection entry point, flap design, and flap fixation concepts that allow aggressive approach to treating both the aged neck and deflated midface.

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.