CHAPTER 11 The “High SMAS” facelift technique
The High SMAS technique was developed in the 1980s as a modification of the procedure described by Tord Skoog in 1974.1 Anatomic studies2,3 have documented the benefit of leaving the skin and subcutaneous mass attached to the SMAS in facial rejuvenation.
The initial challenge was to do so, yet still mobilize the cheek mass adequately. The second goal in designing this procedure was to lift the entire malar and mandibular subcutaneous cheek mass, as a single unit suspended by the SMAS.4 No portion of this repositioning technique was to place the skin on any form of greater than normal tension.
• Evaluate the subcutaneous facial fatty mass particularly looking at variations in volume, shape and position. The malar area descends into the upper buccal region, the anterior cheek descends over the nasolabial fold and the buccal fat accumulates as a “jowl”. The shape turns from an oval shape to a squared appearance. Volume changes affect both the amount of improvement without augmentation as well as the sequence of the operation.
• Analyze the contour of the fatty cheek mass at the mandibular border by looking for jowls. If present, manually reposition the cheek with the patient sitting and feel the thickness of the jowl fat. Here the prominence of the mandibulocutaneous ligament is assessed.
• Evaluate the resting dermal tension to measure the tone of the patient’s skin. Actinic exposure and smoking deteriorates dermal quality at a much more rapid rate manifesting clinically as fine lines in the perioral area for example.
We view the cheek as having two components: the lower two-thirds being the subcutaneous cheek mass; and the upper one-third corresponding to the lower eyelid with its ptotic periorbital structures. Lower eyelid suspension is a necessary adjunct to high SMAS cheek suspension because the two areas overlap.
The sub-SMAS dissection at the level of the zygomatic arch and higher should be performed bluntly. This is safe because the frontal branch of the facial nerve runs deep to the SMAS over the periosteum of the zygomatic arch. Sharp dissection to the anterior border of the parotid is safe. Beyond the anterior border, the dissection should be performed bluntly to avoid the buccal branches of the facial nerve. The plane of dissection as one progresses centrally should stay superficial to the zygomaticus major muscle to avoid peripheral facial nerve branches.
Begin the dissection by elevating the skin flap in the preauricular area about 4 to 5 cm. Elevate only the skin that you anticipate removing. Perform subcutaneous dissection above the zygomatic arch in the lateral orbital area to release the cutaneous attachments of the crow’s feet and to facilitate a smooth redraping of the temporal skin. This maneuver also exposes the superficial side of the upper SMAS that will be divided later (Fig. 11.1).
Fig. 11.1 Extent of subcutaneous dissection.
Fritz E. Barton Jr., The ‘high SMAS’ face lift technique. Aesthetic Surgery 2002;22(5):481–486, with permission of Elsevier.
From the mastoid, carry subcutaneous dissection below the mandible to join the anterior neck dissection, if present. In the neck, the skin and platysma are managed as separate layers because more skin than platysmal advancement is desired. A separate submental approach is added when defatting or when midline platysmal plication is indicated (Fig. 11.2).
Fritz E. Barton Jr., The ‘high SMAS’ face lift technique, Aesthetic Surgery 2002;22(5):481–486, with permission of Elsevier.
Begin dissecting the SMAS in the cheek just anterior to the tragus leaving a cuff for later suturing. Maintain the upper lateral corner of the SMAS at the root of the helix to serve as a point of later fixation. Proper SMAS dissection depth can be safely established here because the facial nerve is well protected by the substance of the parotid gland. Anatomically, the SMAS is fused to the parotid capsule.