Mitz and Peyronie described in 1976 the superficial musculo-aponeurotic
system, or SMAS, the SMAS facelift has become common and has
risen into an operation to which others are compared. The
author’s idea to lift the whole SMAS in the temporal direction
is realised through the surgical technique “Temporal SMAS
Lift by Minimal Hidden Incisions”. This ambulatory SMAS
lift is helpful for changing the “mask of tragedy” into the
“mask of comedy” in cases of beautification, soft tissue laxity
early facial ptosis, and revision facelifts. OBJECTIVE: To
develop a safe and effective ambulatory method to lift the
facial mask, either as a single procedure or combined with
other beautification and rejuvenation methods. METHODS: After
the induction of local anesthesia 1 to 1.5 cm temporal incisions
are made on both sides in the coronal line at the upper level
of the temporal muscle, below the superior temporal crest
line. A blunt dissection is passed in the temporal area between
the coronal and the hairline in the space between the galea
and the temporal fascial. The galea, presenting the SMAS is
pulled up and fixed higher to the upper temporal line and temporal fascia with one
or two sutures. Following this, the skin is closed with single
sutures, without excision. Further, no dressing is necessary.
The hair is washed on the next day and the sutures are removed
in 7 days. RESULTS: This temporal SMAS lift changes the expression
into happy, youthful and smiling appearance, gives apleasing
beautification and rejuvenation of the skin, eyes, brows,
and cheekbones and affects the lower face as well. It is also
possible to combine this procedure with others, such as: rhinoplasty,
chin and lip augmentation, fat reduction and augmentation,
skin resurfacing or blepharoplasty. CONCLUSION: The “Temporal
SMAS Lift by Minimal Hidden Incisions” provides a safe and
effective ambulatory method for beautification especially
in young patients, as well as for rejuvenation of early laxity
and face ptosis.The very short recovery process permits patients
to keep their normal life, work and social contacts.The temporal
SMAS lift is part of the beautification surgery methods on
years ago, the author began correcting the superficial musculo-aponeurotic
system (SMAS) in rhytidectomy. His interest in this procedure
arose as a result from the conclusions made by Tessier in
1974, describing the SMAS. These conclusions were widely exhibited
by two members of his team: Mitz and Peyronie in 1976 .
Since then many authors have dedicated their efforts to studying
thesuperficial musculo-aponeurotic system, which gave rise
to a lot of methods and publications. Since we began the SMAS
lift treatment, we have dissected and mobilised it in different
ways. The dissection, large at the beginning, became more
limited, until the idea that we consider appropriate for achieving
satisfactory results was reached. In 1994 the author firstly
reported his concept of a temporal SMAS lift only, as a treatment
of the suprazygomatic SMAS with effect on the infrazygomatic
SMAS, i.e. the whole SMAS . In the author’s hands this
particular method became a routine ambulatory procedure for
beautification, presented and demonstrated around the world
In art and theatre, the faces called the “mask of tragedy”
and the “mask of comedy” are well known and used to express
age and status. The concept of the author’s surgical method
named “Temporal SMAS Lift by Hidden Minimal Incisions” is
to turn the “mask of tragedy” into a “mask of comedy”, i.e.
to lift up “the subcutaneous facial mask” – the SMAS. Since
soft tissue and skin are attached to the SMAS in the temporal
region, the lifting of the SMAS in temporal direction reflects
in lifting of the face and its most important elements in
the same direction, (Fig. 1) and affects the lower face as
Mechanism of pulling the SMAS facial mask temporally
from one point. Effect on the facial structures.
same idea of a temporal lift is easy to create in the mind
of any lady, beautiful enough or not (Fig.2).
Fig.2. Ladies with no exception are asking for a
temporal lift of the face.
age, the cranium looses on volume and ptosis is shown on the
SMAS, which we can name Loose SMAS, and skin laxity gives
to the face a sad and tired expression. On the other hand,
structuring and positioning different face elements could
be used not only in face ptosis of elderly individuals. Aesthetically
wrong face angles could enhance a sad look also in young patients.
Fixing the SMAS in a higher position aims repositioning of
other soft tissue facial structures as well. Changing the
position of the SMAS could restore the aesthetic angles, shape
and proportions as a basis for beautification and rejuvenation,
to give a happy, youthful appearance and a smiling expression
not only to the elderly. With young patients the aim of the
“temporal SMAS lift” should be beautification, based on face
aesthetics (Fig. 3).
Fig. 3a, b. Before and after surgery. Temporal
SMAS lift changes hanging angles of the eyebrow tail, lateral
cantus of the eye and oral commissure a, b. Better expression
of chick-bone prominence, due to the lifting of the skin and
the fat pad. Additional rhinoplasty is made to correct the
“golden dividing” of the facial proportions in 3 equal parts;
Lip augmentation to equalize lip and eye-with eyebrow volume;
Chin augmentation to obtain the “beauty triangle” and the
straight line of the profile. Embellishment of the face is
obtained and “smiling” expression is present (“mask of comedy”
= fresh and young look).
DESCRIPTION OF THE TEMPORAL AREA AND THE SMAS
SMAS is spread from the platysma to the frontalis, and from
the galea to the vertex, representing the same anatomic layer
. It lies deep to the subdermal vessels and superficial
to the facial nerves. The SMAS acts as a suspension for the
overlying facial skin and distributes forces of facial expression
galea, as the upper part of the SMAS, is a musculo-aponeurotic
tissue and extends from the brow to the occipit and from the
vertex to the zygomatic arch .
temporal region or “temporal pocket” is located over the temporalis
muscle, bordered by the superior temporal crest line above,
by the lateral orbital rim in front, and by the zygomatic
arch below [16-18]. The layer, covering the temporalis muscle,
is a bright and thick aponeurosis, the Temporalis Fascia,
also described as the “superficial layer”, “superficial temporal
fascia”, intermediate temporal fascia, etc.[19-26]. At
the level of the superior orbital rim, the temporalis fascia
splits in two: Superficial and Deep layer of the temporalis
fascia. These fascial layers enclose the intermediate fat
important landmark in the temporal region is the superficial
temporal artery that can be easily palpated. The vein follows
the same pattern . The Frontal branch of the facial nerve,
which innervates the frontalis muscle, the orbicularis oculi
and corrugator supercili, is always medial and inferior to
the anterior branch of the superficial temporal artery .
It lies in the deep layer of the fatty tissue interposed between
the suprazygomatic extension of the superficial musculoaponeurotic
system (SMAS) and the superficial leaflet of the temporal
aponeurosis. It is considered to travel along a line connecting
the base of the tragus to a point 1.5cm above the eyebrow.
the induction of local anesthesia, 1 to 1.5 cm temporal incisions
are made on both sides, in the bicoronal line, at the level
of the upper third of the temporal muscle, just below the
superior temporal crest line. The incision opens the skin,
the subdermal fat layer, and the galea (Fig. 4).
Fig 4a, b, c.
Superior temporal crest line and coronal line are marked blue.
The temporal skin incision is limited 1 to 1.5 cm in the coronal
line, marked with red line. The sutures of the temporal SMAS,
to lift it to the point of fixation to the temporal fascia,
are marked with black lines: first, in the direction of the
eyebrow and the eye; second, in the direction of the lower
face. Each one could be sufficient to solve different problems
on the face.
The 1 to 1.5 cm long temporal skin incision is made in the
blunt dissection is passed temporally from the coronal to
the hairline in the space between the galea and the temporal
fascia, using a scalpel hand-piece (Fig. 5).
Fig. 5a, b, c. A. Blunt opening of skin and galea
incision (tf = temporal fascia, g = galea). b. Blunt dissection
between galea and temporal fascia. c. galea (g) and temporal
fascia (tf) are visible
galea is sutured using three simple steps: 1) A non-absorbable
suture 3.0, with a large diameter needle, is introduced in
the subgaleal space in the direction of the eyebrow and a
puncture is done through the galea and the skin (Fig. 6a).
2) The needle is introduced back into the same puncture, then
is passed subcutaneously and another puncture is done trough
the skin in the lower face direction (Fig. 6b). 3) Through
the last puncture back, the needle is introduced under the
galea in the direction of the incision (Fig. 6c). All three
steps need to be completed to fix the galea. 4) The next stitch
is made through the upper temporal line and temporal fascia in the upper direction
(Fig 6d). The suture of the galea to the temporal periosteum and fascia is
done under elastic pressure (Fig 7a) Thus, the whole SMAS
is pulled up in temporo-occipital direction. The galea, presenting
the SMAS is pulled up and fixed higher to the temporal fascia
with one or two sutures on each side (Fig 4a). Following this,
the skin is closed with single sutures and no dressing is
necessary (Fig. 7b). The next day hair washing is recommended
to remove blood residuum. Sutures are removed in 7 days.
Fig. 6 a,b,c,d. A First stitch starting from the
incision under the galea, b. second stitch above the galea,
c. 3rd stitch under the galea back to the incision, d. 4th
stitch trough the temporal fascia.
Fig. 7 a,b. A This particular suture is fixing galea
in higher position to the temporal fascia, b. skin is closed.
patients were operated from January 1993 to May 2001. Patients’
age ranges from 19 to 53 years. The operation is done ambulatory
and after washing and styling the hair, patients can return
to their normal social life on the same day (Fig. 8a,b). The
temporal SMAS lift has effects on the suprazygomatic area:
it reduces the lateral and forehead wrinkles; raises the eyebrow
tails and the lateral cantus of the eyes; reduces the crow's-foot
wrinkles, raises the cheeks' fat pad into a better cheekbone
prominence and tightens the skin. (Fig. 9a,b). The effects
on the lower face are collateral. The SMAS elevates the oral
commissure; it improves the skin adaptation reducing its cheek
flaccidity; gives a clearer outline of the jaw (Fig. 10a,b).
Generally, the method gives excellent results in younger and
middle aged patients whose lower face is minimum to medium
affected The tissues are repositioned to the desired higher
youthful position. The temporal hair is preserved. There are
no visible scars, no sign of operative intervention, and no
"operated-on" appearance. A moderate tension in
the face could be present for hours or days. The feeling is
mostly pleasing. Only 7 patients described the tension as
inconvenient for one or two days. During the first night 5
patients reported headache. On day 1 after surgery there is
no swelling and business people can work normally. A lower
eyebrow swelling could appear on day 2 and 3 in approximately
30 % of the patients and can be prevented by resting in the
supine position during the first two days. Two patients had
lower lid bruising on one side and another one – on both sides.
Three patients reported a crust formation and a liquid formation
under the crust. The reason was interposition of hair in the
suture sling for galea fixation. After its removal, the wounds
healed in approximately two days. A patient had the same problem
in another country and the surgeon removed a suture. No other
infections, no hematomas or damage on the facial nerve were
observed. A palpable fold in the temporal area could be present
in some cases and it stays for a week.
most important thing in face lifting is its long-term fixation.
Numerous factors act against face stability, such as gravity
and mimic. The longevity of the result is improved due to
the SMAS fixation. This is best seen years after surgery in
cases of a unilateral temporal SMAS lift in facial paralysis,
post traumatic and postoperative canthal abnormalities. (Fig.
patients, who could not see the difference, despite the photograph
demonstrations, contested the aesthetic result. The effect
of lifting angles was not satisfactory with 5 patients. With
3 of them the operation was repeated after 3 to 5 years.
Fig. 8 a,b. Before and immediately
after a temporal SMAS lift and rhinoplasty. The absence of
visible signs of operation permits immediate return to social
Fig. 9 a,b. Before and after a temporal SMAS lift.
Visible elevation of the eyebrow tail and the lateral cantus
of the eye reduction of the crow's-foot wrinkles elevation
of the cheeks' fat pad into a better cheekbone prominence;
tightening and beautification of the skin.
Fig, 10 a,b. Before and
after a temporal SMAS lift. Visible changes in the suprazygomatic
as well as in the infrazygomatic area. Beautification and
rejuvenation are obtained.
Fig. 11a,b. Before and after a unilateral
temporal SMAS lift in facial paralysis. A 4-year result. The
whole left side is elevated and the nose is positioned in
the middle by the temporal SMAS pull.
there are plenty of techniques used for face-lifts: conventional
rhytidectomy composite face-lifting, deep layer rhytidectomy
sub-SMAS, extended face-lifting, subcutaneous temporofacial
lift combined with SMAS suspension, medial SMAS lift with
aggressive temporal skin takeout, temporal lift via blepharoplasty
approach, but stretching the skin solely is obsolete. New
techniques were proposed, such as endoscopic subcutaneous
and SMAS, subperiosteal, extended face and browlift etc. [30-48].There
is no general agreement and no definitive answer as to which
operative technique is most effective or preferable in each
specific case. This is due to the subjective nature of aesthetics
and desires, to the variability of skills and anatomy.
the last years an increasing number of patients ask for mal
result with minimal surgery and recovery time, corresponding
to the modern lifestyle. The temporal SMAS lift by minimal
hidden incisions is the most preferred one by our patients
as an optimal solution for face beautification that preserves
the natural look.
Fig. 12 a, b. Before and after a temporal SMAS lift,
rhinoplasty and ultrasonic liposculpture of the double chin.
Anatomically different problems on the face are solved in
one session using different surgical techniques.
temporal SMAS lift is a nice weekend ambulatory procedure
that gives a pleasing rejuvenation and beautification of the
skin, eyes, brows, cheekbones, and most importantly, changes
the expression. In young ladies, only one suture per side
is usually enough to lift the lateral cantus of the eye, the
eyebrow and to pull the ptotic malar fat back in place to
form a nice malar eminence. It is also possible to combine
this procedure with other procedures such as: rhinoplasty,
chin and lip augmentation, fat reduction and augmentation,
skin resurfacing or blepharoplasty (Fig. 12a, b).
SMAS lift provides a safe and effective method for beautification,
as well as for rejuvenation in early laxity and face ptosis,
and for some revision facelifts.
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P. Serdev, MD, PhD
Surgery and Aesthetic Medicine Medical Center
11 Dvadeseti April Str., 1606 Sofia, Bulgaria
Tel: +359 88 802004
Fax : +359 2 9515668
Society of Aesthetic Surgery and Aesthetic Medicine
for publication: 31 05 2001