Indications and Technique for Extended SMAS Face-Lift and Necklift
James M. Stuzin
Sammy Sinno
DEFINITION
Facial aging is the result of many changes that occur in the skin, soft tissues, fat, and facial skeleton.
Early attempts at surgical facial rejuvenation were skin tightening procedures.
The works of Skoog, Mitz, and Peyronie demonstrated that soft tissue repositioning of facial fat can restore a more youthful facial contour.1
The primary advantage of skin and superficial musculoaponeurotic system (SMAS) flap elevation separately is greater aesthetic control in terms of repositioning facial fat independent of skin flap redraping.
Another major advantage of an extended SMAS flap technique is the ability to restore facial shape of youth by building volumetric highlights over the anterior and lateral zygoma juxtaposed with submalar concavity.2
ANATOMY
The layers of the face are skin, subcutaneous fat, SMAS, the muscles of facial expression, deep fascia or parotidomasseteric fascia, and the plane of the facial nerve, parotid duct, and facial vessels.
The thickness of these layers, particularly the SMAS, varies region to region.
The muscles of the face are all innervated on their deep surface except for the deepest muscles of facial expression, which are the mentalis, levator anguli oris, and buccinators.
The parotidomasseteric fascia protects the facial nerve branches in the preparotid area (FIG 1).
PATIENT HISTORY AND PHYSICAL FINDINGS
The patient presenting with facial and neck aging demonstrates volume decent, deflation, and radial expansion of facial soft tissue from the center of the face to the periphery.
The extended SMAS technique attempts to address these concerns by repositioning and conforming the descended facial fat to more aesthetically pleasing areas of the facial skeleton.
On physical examination, the skin quality, elasticity, amount and location of subcutaneous fat, depth of the nasolabial fold, degree of jowling, deflation, skeletal support, malar convexity, and submalar concavity are noted.
Platysma position and descent are similarly examined.
SURGICAL MANAGEMENT
Preoperative Planning
Patients are asked to bring pictures from their youth. Although patients cannot be made to look exactly like they were when younger, a similar facial shape to youth can be restored with this technique in many patients.
Antibiotics are started 1 day before surgery and continue for 5 days afterward.
An intertragal incision is marked along with a temporal incision and partial hairline retroauricular incision.
Positioning
The patient is in a supine position for this procedure.
Induction of anesthesia is achieved with midazolam and fentanyl.
Ketamine is given for local injection, which is a mixture of lidocaine and bupivacaine.
Propofol and valium drips are used on an as-needed basis at the discretion of the anesthesiologist.
Approach
A submental incision just caudal to the submental crease is used for neck contouring.
 FIG 1 • A. Cadaver dissection in the parotid area showing the parotidomasseteric (or deep facial) fascia. B. When the parotidomasseteric fascia is reflected, the branches of the facial nerve are visualized. |
TECHNIQUES
▪ Extended SMAS Face and Neck Lift
Incisions and Dissection
The partial hairline retroauricular incision is made with a no. 15 blade.
A no. 10 blade is used in the postauricular region for the adherent fascial dissection over the adherent cervical skin ligaments overlying the sternocleidomastoid (SCM).
The other incisions are dissected with a no. 15 blade. In the temporal area, dissection is carried deep to the temporoparietal fascia. Deep dissection here protects the hair follicles and tends to be avascular. However, the superficial temporal artery must be ligated.
The beginning of the subcutaneous dissection over the lateral fat compartment is fascial. Using facelift scissors, the interface between the SMAS and the fat can be precisely raised with transillumination.
When extending the subcutaneous dissection inferiorly, take care to stay superficial above the cervical fascia overlying the SCM to avoid injury to the great auricular nerve.
As the anterior subcutaneous dissection proceeds from the lateral to middle superficial fat compartment, the dissection becomes easier as proceeding distal to the ligaments overlying the parotid.
Skin flaps should be dissected thinner in the region overlying where the SMAS is to be dissected to leave more fat on the SMAS for subsequent SMAS flap elevation (and avoidance of tearing).Related posts:
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