As we age, our skin and tissues lose their elasticity, leading to the appearance of wrinkles and sagging skin. The cosmetic industry addresses these issues with various anti-aging products containing ingredients such as vitamin C, hyaluronic acid, and more to help people maintain the integrity of their skin. However, many individuals prefer immediate solutions with quick results rather than long-term actions without clear outcomes. The medical field, particularly plastic surgery, has achieved what they desire.
One of the most significant structures for maintaining the face is the Superficial Musculo-Aponeurotic System (SMAS), consisting of a tissue layer that exists in the deep internal layers of the skin.
SMAS facelift is an advanced facelift technique that focuses on the lower two-thirds of the face. This procedure can provide excellent, long-lasting results in cosmetic rejuvenation by addressing the supporting layers of facial tissue.
SMAS facelift surgery is a complex treatment that involves a deep understanding of facial anatomy, a specialized set of surgical techniques, and highly developed aesthetic skills. Not all cosmetic surgeons receive training in facelift surgery during their education or in-depth specialization in specific types. It is crucial to research before choosing a facelift surgeon, as someone with superficial knowledge and no specific experience can cause irreversible damage to your face – from damaged nerves and muscles to facial paralysis, inflammation, unsightly scars, disproportion, or simply not adequately addressing excess skin and the muscles beneath it, resulting in a short-lived rejuvenation effect. On the other hand, a reputable plastic surgeon with established results in facelift procedures can work wonders and restore your youthfulness.
What is SMAS Facelift?
As the skin on your face ages, it loses elasticity both in the epidermis and in the SMAS membrane. This loss results in sagging cheeks around the jawline, sagging jowls, and in some cases, a double chin. Subsequently, cheek fat will descend forward, revealing nasolabial folds.
With age, the SMAS layer descends toward the lower two-thirds of the face and the neck. The appearance of a "turkey neck" is formed by the anterior border of the platysma muscles in the neck.
By tightening the muscles, removing fat, and reducing excess skin, SMAS facelift can alleviate some visible signs of aging.
SMAS facelift can correct the following:
• Sagging in the middle of the face
• Drooping cheeks
• Nasolabial folds
• Jowls
• Sagging fat
• Loose skin and fat under the chin and jaw
• Neck sagging
Superficial Musculo-Aponeurotic System (SMAS) Anatomy
The Superficial Musculo-Aponeurotic System (SMAS) is a layer of fibrous tissues and muscles that starts slightly in front of and below the ear and extends downward to the neck.
As a continuous fibromuscular tissue, this thin but strong layer covers and unites the muscles and tissues of the face, midface, and neck. It includes muscular areas, fat pads, and the entire cheek area, as well as attachments to the platysma, a superficial muscle that covers the lower part of the face, jaw, and neck muscles.
As age advances, the platysma muscle in the neck produces vertical muscle bands and a "turkey neck." This fibrous layer is subsequently concealed behind fat tissue (adipose tissue) and the skin layer. The function of the SMAS is to support the mimetic muscles crucial for facial expressions in their normal position.
Advantages of SMAS Facelift
Some features of the SMAS Facelift include:
• Surgical time ranges from 1 1/2 to 5 hours
• Repositioning the SMAS leads to a vertical lift of the face and neck
• Elimination of sagging/turkey neck and sagging of the jawline
• Achieves a youthful and natural appearance
• Deep removal of wrinkles with long-lasting results
• Relatively straightforward treatment with minimal complications
Who is a good candidate?
In general, if you have significant wrinkles and skin laxity, you may be an excellent candidate for this surgery. Candidates should have a consultation to determine if the condition of their skin is suitable for this operation or if alternative treatments are more appropriate for their cosmetic goals. Patients considering this surgery often express concerns such as:
• Loose skin
• Moderate to severe wrinkles
• Sagging jawline
• Sagging cheeks
• Double chin
• Poor jawline definition
Since this is a surgical procedure involving invasive techniques and general anesthesia, you must be thoroughly qualified as a candidate before planning your treatment. This involves completing specific lab and blood tests before your treatment is scheduled. Some qualifications to assess if you are a good candidate for this surgery include:
1. Good Health: Patients should be in excellent health, without any medical conditions such as high blood pressure, diabetes, asthma, or cardiovascular problems. Good health will reduce risks if general anesthesia is required for your procedure. Your overall health will also affect how well you recover from the treatment, as individuals in good condition generally recover faster and more easily.
2. Elasticity of the Skin: The condition of your skin is crucial, and it should retain some natural elasticity and flexibility for the technique to be as successful as possible. Essentially, your skin should still have some "bounce" for this technique to be optimally effective. Skin elasticity can be tested by pinching it and observing how quickly it smoothens. If your skin still feels pinched, you may not be a good candidate for this surgery. Overly aggressive skin tightening leads to unnatural results.
3. Balanced Bone Structure: Easily overlooked but ideal candidates for this surgery are individuals with a naturally balanced bone structure. To achieve optimal benefits from the therapy, the bone structure should be symmetrical. Of course, if the fundamental bone structure is not suitable for this therapy, other plastic surgery techniques can correct asymmetries, or you can use fillers to sculpt your face for the best results.
4. Realistic Expectations: You should also set realistic goals. On average, this surgery can remove 10-15 years from your face, but factors such as skin condition, genetics, and skin type can influence how much younger you appear after the surgery. This technique merely lifts and tightens the skin; it does not address other issues such as those related to your bone structure.
5. Commitment to Maintaining Results: Patients desiring this surgery should ideally commit to maintaining the results of the treatment. The benefits of your procedure will last several years, but you will get the most out of them if you are proactive about your skin health. Using active skincare products like retinol and protecting your skin from UV rays by wearing SPF during the day may help you preserve your results for a more extended period.
SMAS Facelift Contraindications
Poor medical health, individuals regularly taking blood-thinning medications, patients with unrealistic expectations, and heavy smokers are relative contraindications. Fine wrinkles that can be effectively treated non-surgically or conservatively are contraindications for facelift surgery. Secondary facelifts should also be performed with caution, as scarring from previous treatment can alter the initial tissue planes, increasing the risk of facial nerve damage.
How to Determine If You Need a Facelift?
For most people, cosmetic surgery is a "want" rather than a "need." However, there may be certain warning signs to look for to assess whether you could benefit from a facelift procedure. For example, you can perform a simple "pulling" test at home to see if this technique will help you achieve your aesthetic goals. Simply stand in front of a mirror and use your fingertips to gently pull the skin around your ears forward. If this movement also lifts the skin on your cheeks, you may find this procedure beneficial.
Naturally, since everyone's needs and skin types vary, the signals that this procedure may be suitable for you will differ. However, a few examples show that now is the optimal time for this treatment, such as:
• Deep Wrinkles on the Lower Part of the Face
• Prominent Jowls
• Sagging Jawline
• Double Chin or Sagging Neck
Types of SMAS Facelift
SMAS facelifts are classified into five types: plication, imbrication, extended, high, and deep plane. Each of them refers to a slightly different method of lifting and securing the SMAS layer. Surgeons have performed many of these types of lifts over the years. Our current belief is that the deep plane SMAS lift provides the most natural and long-lasting results with the fastest recovery, but alternative forms of facelift have also yielded good results for some people. The two most common types of SMAS facelifts are described below:
SMAS Plication Facelift
• Procedure: The introduction and description of SMAS by Mitz altered the concept of facelifts. This approach was proposed as a new means of manipulating subcutaneous tissues to address senile changes in the face, such as superficial wrinkles and deep soft tissue sagging simultaneously. The fibromuscular nature of the SMAS layer offers greater resistance to gravity than the skin. The idea behind the SMAS plication method is to manipulate a stronger layer that can withstand higher loads than the skin. In this approach, the dissection plane is supraSMAS. The SMAS layer becomes visible after dissection in the subcutaneous plane. The mobile section of the SMAS layer is connected to the posterior relatively immobile layer (i.e., the parotidomasseteric fascia) through three vertical stitches. To prevent puffiness, excess SMAS layer can be trimmed after stitching. This method is recommended for people aged between forty and fifty with thin skin and moderate to severe sagging. This approach is not suitable for overweight individuals with thick skin.
• Advantages: SMAS plication appears to be a simple treatment with minimal risk of facial nerve injury. Despite manipulating the SMAS layer, the dissection plane lies above this layer and the facial nerve plane, making this approach generally safe. The procedure has minimal operating time, and the recovery time is favorable. This approach can lead to a visually more beautiful result in the middle of the face than DPFL. SMAS plication, on the other hand, may allow the surgeon to control skin movements more effectively than MACS lifting and is less invasive than subSMAS treatments.
• Disadvantages: This treatment is a greater challenge than DPFL for addressing neck aging due to insufficient release of the connections between the facial layer and the platysma. SMAS plication is more invasive than other types of lifting, such as MACS lifting. The surgeon is unable to manipulate the deep-seated soft tissues under the SMAS layer, leading to much shorter-term effects compared to DPFL.
Extended SMAS Facelift
• Procedure: Lemm's description of subSMAS dissection was quickly embraced by aesthetic surgeons. The main principle of subSMAS modifications is to maintain skin redundancy by modifying deeper soft tissues (i.e., the SMAS layer). While SMAS plication seems to provide better results when the SMAS layer is thin, dissection of thick SMAS layers yields superior results. The primary approach for this method is to dissect and pull the skin and SMAS flaps separately. The skin flap is initially dissected in the subcutaneous plane. After incising the SMAS layer, dissection is performed in the subSMAS plane. There are five critical points during an extended SMAS facelift:
1. The first point is 1 cm below the zygomatic arch, which is the origin of the frontal branch of the facial nerve. The incision to start sub-SMAS dissection is from this point.
2. The second notable point is the starting point for releasing and dissecting the platysmal auricular ligament. This second point is 3 cm below the soft part of the ear.
3. The third point is 5 cm below the mandibular angle, representing the lower degree of subplatysmal dissection.
4. The fourth notable point is the anterior border of subplatysmal dissection, identified with the facial vein where it crosses the lower border of the mandible.
5. The last notable point is the zygomaticus major muscle, which is the anterior border of sub-SMAS dissection in the cheek.
The vector of stretching the SMAS layer differs from that of the skin. The retracting vector of the SMAS layer is more vertical than that of the skin flap. To enhance the jawline and neck contour, the SMAS and platysma flaps can be adjusted in the postauricular area. The SMAS flap advances superolaterally into the area of the malar fat pad, perpendicular to the nasolabial fold.
• Advantages: By independently adjusting the skin and SMAS flaps, the surgeon is better able to reverse the signs of aging. As facial attachments are released, and the malar fat pad is repositioned, the results of this method are long-lasting. As mentioned earlier, we are able to replace the fat pad with this approach. Continuous SMAS-platysmal flap can be used to provide optimal results for the lower part of the face and neck. Separating the skin and SMAS flaps reduces tension on the skin flap, preventing the artificial appearance of the skin found in other facelift procedures.
• Disadvantages: This approach requires more time for execution than other modifications. To separate the soft tissues of the face into two different sections, this operation is technically sensitive and requires a lot of experience. This approach carries a significant risk of facial nerve damage. Extensive dissection of skin segments increases the risk of necrosis. In this procedure, impaired viability of the skin flap is a key issue. For younger individuals with minimal signs of aging and a youthful lower face and neck, this operation is not recommended. In these cases, less invasive procedures like short-scar facelift methods are used.
SMAS Facelift Costs
The cost of plastic surgery on the SMAS layer varies depending on the individual, their specific facelift needs, and the skills of the surgeon. A SMAS facelift can range from an average of 5,000 euros to 15,000 euros or more.
Keep in mind that the money you spend on a facelift is a direct investment in yourself and your confidence.
What Happens After a SMAS Facelift?
After the SMAS facelift surgery, medical professionals will transport you to an observation room while you recover. Once stable, you will be allowed to leave the hospital, which typically takes a few hours.
Bandages may be wrapped around your face to help reduce swelling and bruising. Small drainage tubes may also be present. Your surgeon will provide specific instructions for recovering from the facelift surgery, including how to care for the incision site(s) and drainage, and will schedule a follow-up visit before you leave. If pain medication is required, your surgeon will prescribe it.
SMAS Facelift Recovery Time
The recovery time for a facelift depends on the type of surgery and your overall health. Bruising and swelling may persist for several weeks. However, it may take two to three months for your face to feel "normal" again.
Complications/Risks Associated with SMAS Facelift
The issues related to facelifts can include, but are not limited to, the following:
1. Nerve Damage: Together with numbness or changes in skin sensation, damage or weakening of the facial nerve may occur. This can be temporary or permanent.
2. Infection and Anesthetic Response: As with any surgery, there is a risk of infection and anesthetic response.
3. Hematoma: A hematoma, or blood collection under the skin, may form. Physicians typically remove them.
4. Slower Healing Rate: Smokers, in particular, may experience a delayed recovery phase after a facelift. Smoking in the months before or after the surgery may contribute to skin damage and lasting scars. If you actively smoke, your surgeon may refuse to perform the procedure.
5. Scarring: Improperly treated scars can become more pronounced or thicker than expected. This may require additional therapy or correction.
Conclusion
The SMAS (Superficial Musculo-Aponeurotic System) is the layer of facial expression muscles enveloped in their own connective tissue. It is located beneath the skin and subcutaneous tissue, constituting one of the most important supporting structures for the face and neck. Manipulating this anatomical structure alters the appearance of the face and neck.
SMAS rhytidectomy, also known as SMAS facelift, is a surgical procedure that corrects the sagging appearance of the neck and lower two-thirds of the face. It is performed to address sagging skin, excess fat, jawline issues, and loss of volume in the cheeks. It is less invasive than traditional facelifts, which target the superficial skin of the face, and recovery is quicker.
