Rhytidectomy is a procedure that continues to evolve as surgeons seek to offer patients natural rejuvenation with reduced morbidity. Over the years, we have witnessed an evolution of techniques ranging from basic skin lifts to superficial musculoaponeurotic system (SMAS) procedures to even more complex, deep-plane operations in search of an operation that reliably restores facial form with minimal morbidity.1 More recently, the need for extensive incisions for rhytidectomy has also been questioned. It has become increasingly clear that not all patients require the full classic temporal preauricular and retroauricular incisions.2 The incision, as well as the planes or levels of facial dissection, should be individualized for each patient, in-keeping with the physical changes related to aging and the desired result. As more patients seek facial rejuvenation at an earlier age, the need for surgical solutions that are less invasive and that involve less downtime is becoming increasingly important.3
When SMAS dissection first became popularized after the work of Mitz and Peyronie in 1976, many surgeons dissected the SMAS directly overlying the parotid gland developing a SMAS flap which was rotated to elevate the deeper tissue. I (the author) initially utilized this form of SMAS dissection beginning in the late 1970s and continued with it into the mid-1980s but overall, was disappointed with the effects of a simple elevation and tightening of the lateral superficial fascia. Specifically, there was little difference in overall facial contour whether I had performed a SMAS flap or plication.
As greater experience was gained with SMAS dissection, it became obvious that for the superficial fascia to produce any effective contour change in facelifting, it was necessary to elevate the SMAS anterior to the parotid gland. The problem of more extensive SMAS dissection is that facial nerve branches are placed in greater jeopardy.4,5 It was also noted that the superficial fascia tends to thin out as it is dissected more anteriorly, making the SMAS easy to tear. A SMAS dissection that is not raised as a continuous fascial sheet but rather is raised with several tears in it is a poor substrate for holding the tension of contouring the face. For these reasons, the author felt that an extensive SMAS dissection was often not warranted in most patients and offered little long-term benefit when compared with SMAS plication.
In 1992, the author realized that an alternative to formal elevation of the SMAS was to perform a “lateral SMASectomy”, removing a portion of the SMAS in the region directly overlying the anterior edge of the parotid gland at the interface of the fixed and mobile SMAS.6 Excision of the superficial fascia in this region secures mobile anterior SMAS to the fixed portion of the superficial fascia overlying the parotid. The direction in which the SMASectomy is performed is oriented so that vectors of elevation following SMAS closure are perpendicular to the nasolabial fold or even more vertical, thereby producing improvement not only of the nasolabial fold but also of the jowl, jaw line, and midface.
The advantages of lateral SMASectomy are several when compared with formal SMAS elevation.7 First, since the procedure does not require a formal SMAS flap elevation, there are fewer concerns about tearing of the superficial fascia. Second, the potential for facial nerve injury is less because the majority of the dissection is carried over the parotid gland. If the SMASectomy is performed anterior to the parotid, the deep fascia (parotid masseteric fascia) similarly will provide protection for the facial nerve branches as long as the resection of the superficial fascia is done precisely and the deep facial fascia is not violated. Third, because SMAS flaps have not been elevated, they tend to be more substantial in terms of holding suture fixation, and the problems of developing postoperative dehiscence and relapse contour are reduced.
Because of the design of the lateral SMASectomy along the anterior border of the parotid, the SMASectomy is performed at the interface of the superficial fascia fixed by the retaining ligaments and the more mobile anterior superficial facial fascia. On closure, this brings the mobile SMAS up to the junction of the fixed SMAS, producing a durable elevation of both superficial fascia and facial fat. In contrast, simple plication pulls on unreleased facial fascia (still bound by the retaining ligaments) such that proper vectors of elevation and obtaining long-lasting fixation can be problematic.
In the author’s practice, utilizing the lateral SMASectomy technique, we are confident that we can obtain consistently good results with minimal risk, complications, and morbidity, and a speedy postoperative recovery. This method represents a rapid, safe, and reproducible operation, allowing the surgeon the versatility obtained with formal SMAS flap undermining while producing both the safety and rapidity of SMAS plication. However, we not apply this technique in every patient, and patients with a thin face, where fat needs to be preserved, get an excellent result with just a skin undermining, SMAS plication and redraping.