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Manipulating The Superficial Musculoaponeurotic System (SMAS)

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Manipulating The Superficial Musculoaponeurotic System (SMAS)
June 28
17:05 2016

Article Highlights

  • A facelift surgery can help to provide a youthful facial rejuvenation while still achieving a lifting result. Several of these methods involve manipulating the superficial musculoaponeurotic system (SMAS)
  • The SMAS layer and skin start to lose their strength and laxity which causes the “sagging appearance”
  • The ideal patient is male/female with reasonable expectations. They have neck laxity and jowls, which is a result of soft tissue descent that is part of the natural aging process
  • Every individual has a different type of skin tissue and can age differently. Skin tissue type can vary between thin skin, moderate-thick skin and thick skin

The latest techniques in facelift surgery can help to provide a youthful facial rejuvenation while still achieving a lifting result. Several of these methods involve manipulating the superficial musculoaponeurotic system (SMAS). Prior to the development of the SMAS technique, surgeons performed facelifts that lifted only the skin, resulting in over-corrected facelifts. This was most apparent in the ‘70s to the late ‘80s. In contrast to those earlier facelifts, these modern techniques allow the surgeon to lift a combination of the facial muscle tissue and the skin. This technique introduces a more natural approach to facelift surgery.

The majority of women now seeking facelift surgery want a facial appearance that looks rested and rejuvenated. “Women who are looking for facial rejuvenation by way of a facelift are looking to achieve a younger version of themselves. They don’t want to look different,” says Dr. Scott Walen, a facial plastic and reconstructive surgeon at Saint Louis University. “They don’t want to look ‘done’. This is how facial rejuvenation surgery differs from breast augmentation for instance. They want the appearance of restfulness, relaxation and youth,” explains Dr. Walen. He feels the surgery is technically challenging and involves an aspect of creativity and art, which is different from most non-cosmetic surgeries. 

As we age, both the SMAS layer and skin start to lose their strength and laxity which causes the “sagging appearance”. The modern facelift using SMAS manipulation techniques, tightens and repositions the cheek area, the jawline, the jowls and the neck. Underneath the surface of our skin is a thin layer of tissue that covers our facial structures and facial regions. This layer is identified as the SMAS layer. The SMAS layer contains connective muscle tissue and fat. The surgeon will tighten the SMAS layer along with the loose skin. The surgical incision can depend on each surgeon and how they prefer to access the loose tissue. Typically, the incision starts underneath the sideburn area, traces down along the preauricular crease and slightly to the inside of the tragus. The incision goes down along the earlobe and is hidden behind the ear. The surgeon will then access the tissues from these areas. The lift is held in place by sutures.

Dr. Walen elaborates further on how the procedure works. “You identify the SMAS through a hidden incision around the earlobe, elevate a small amount of the SMAS, and then lift the tissue up and back followed by suturing to stable parts of the face and neck” he explains.

The new concept is the vertical lift where the tissue is raised up and back, versus the old facelift technique of just bringing the SMAS back. Patients appear “windswept” with the old technique. Dr. Walen says the new concept achieves natural, youthful and long-term results compared to the facelifts of the past, where the results were not long-lasting. 

The results achieved by a SMAS full facelift will typically last anywhere between eight (8) to ten (10) years depending on the patient. By lifting the SMAS layer, the results can last longer than the aforementioned skin-only lift. However, various factors can affect how long the results last. These factors include: a person’s skin tissue, BMI, pre-existing medical conditions, overall health, genetics and other skin conditions.

Every individual has a different type of skin tissue and can age differently. Skin tissue type can vary between thin skin, moderate-thick skin and thick skin. A patient with heavier skin tissue may find that the result will not last a full ten years, simply because the weight of the tissue is fighting against the lift. Most surgeons will have a pre-determined BMI maximum for patients as a higher BMI can result in having a limited lifting effect. Also, the overall health of the patient and general skin condition with respect to sun damage also impacts the results. Smoking is a negative factor that will increase some of the risks that are associated with this surgery as smoking reduces the oxygen flow and blood supply to the face. Most surgeons will recommend for a patient to not undergo this surgical procedure if they are habitual smokers. 

“The ideal patient is male/female with reasonable expectations. They have neck laxity and jowls, which is a result of soft tissue descent that is part of the natural aging process,” according to Dr. Walen. In most patients, these visual signs occur in their late 40s. They vary depending on genetics, previous skin care, previous facial surgeries and general medical condition. “Patients that have multiple systemic medical conditions and those who have not taken care of their skin may experience those aging changes to the face earlier,” says Dr. Walen. Tobacco, alcohol and drug abuse are also contributing factors.

This surgery is generally performed under general anesthetic and completed within a surgical timeline of four to six hours. In select situations, this procedure can be performed under sedation. As with any procedure performed under general anesthetic, SMAS full facelift surgery has risks to consider. The probability of each risk depends on each patient’s previous health and skin tissue. Your surgeon should be able to explain these risks with you on an individual basis. Some of the risks include and are not limited to:

  • Risks of general anesthetic: during your pre-operation time, your surgeon will most likely send you for specific blood and heart tests that will determine if you are healthy enough to undergo surgery. Risks include heart attack, stroke and death.
  • Infection: infection is possible in all different types of surgery. To lower this risk, your surgeon will prescribe you antibiotics to take post-surgery.
  • Skin necrosis (skin death): the percentage of this risk increases in smokers. Skin necrosis of the scar and/or around the scar can also occur from infection.
  • Facial nerve injury (nerve damage of facial nerves): depending on which facial nerve is injured, nerves can take six months to one year to heal. In some cases, nerve injury can result in mouth ptosis.
  • Hematoma (collection of fluid and/or blood): this can occur underneath the skin as a result from swelling. Immediate attention is given to the patient if this were to happen.
  • Undesired scar healing: a scar can heal in a way that may not be the desired result. Further scar revision procedures may be needed.
  • Pixie ear deformity: this can happen when the earlobe position point is positioned too low onto the facial structure. Sometimes it is due to tension. Future revision may be required. 

During your pre-operation appointment, your surgeon should discuss with you the options of pain management that may include prescribed narcotics or over-the-counter medications. They will make recommendations on how to care for the incision area. You should be informed of what you will need to avoid before and after surgery, which can include a list of medications and vitamins. Follow-up appointments after surgery are very important as the surgeon can monitor the accumulation of swelling and your healing process. Depending on the surgeon’s preference, you should have a follow-up appointment one week post-operation, two weeks post-operation, one month post-operation and further into the future. After surgery, it is best to have a family member, friend or nurse with you for the immediate care you will require. You will need this care for at least the first three days following surgery for your comfort and safety.

The healing time that patients will need is roughly two weeks. However, it can take up to a full six months for all of the swelling to completely subside. Within the first two weeks of the healing process, you will experience swelling, possible bruising and some discomfort. 

“Facelift surgery is gratifying because we know that this procedure can impact a patient’s self-esteem and well-being,” comments Dr. Walen. He believes when a patient feels that they look younger, they live younger; this changes many aspects of their life in a positive way. 

With a number of exciting new advancements in facelift surgery, surgeons are able to further provide patients with progressive techniques to rejuvenate the face and neck. Modern facelift techniques that involve the SMAS layer, adopted by a growing number of surgeons, can help you achieve a rested and refreshed appearance for your entire face.

About Author

Kelsey Chisholm

Kelsey Chisholm

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1 Comment

  1. lakeisha tom August 17, 14:09

    Just desire to say your article is as astonishing. Thanks one million and please keep up the rewarding work.

    Reply to this comment

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