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 IJCS / Year: 2001 / Volume 1 - Number 3 / Original Papers
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Title: LOWER SMAS-PLATYSMA FACE LIFT USING HIDDEN RETRO-LOBULAR APROACH
Nikolay P. Serdev, MD., PhD.
Pages: 1 - 7/
 
 

LOWER SMAS-PLATYSMA FACE LIFT USING HIDDEN RETRO-LOBULAR APROACH
NIKOLAY P. SERDEV, M.D., PH.D.
Head of Medical Center "Aesthetic Surgery and Aesthetic Medicine", 11 "20th April" St., 1606 Sofia, BULGARIA
President of the Bulgarian Society of Aesthetic Surgery and Aesthetic Medicine

SUMMARY

The idea of lower superficial muscle-aponeurotic system (SMAS)-platysma face lift with hidden incisions in the retro-lobular fold gives the answer how to re-structure and re-position the face and it's elements in the lower part - without visible preauricular and retro-auricular scars. The only place to hide the incisions and at the same time to have the best approach to the cheek SMAS and platysma in a radius of a minimum of 3 cm from the tragus, is the fold behind the earlobe. It normally permits a 1.5 cm long incision that is enough to work preauricularly: to elevate (without dissection) preauricular SMAS and retromandibular platysma into the skin opening and to suture them to the mastoid. Fixing SMAS in a better position aims repositioning of other soft tissue facial structures as well. Changing the position of SMAS could restore the aesthetic angles, shape and proportions as a basis for beautification and rejuvenation and to give a happy, youthful appearance and smiling expression not only to the elderly. In young patients the aim of SMAS lift has to be beautification based on face aesthetics, and first of all: cheekbone beautification with concave shaping of the so called "hungry cheeks" - much loved by young people. Outlining the submandibular space is yet another objective of the lower SMAS-platysma lift. The lower SMAS lift gives a harmonious and strong lifting of the lower third of the face and creates an acute cervicofacial angle. It achieves a bidirectional lower face and neck lift, soft correction of the nasolabial fold and correction of submental area laxity. It is also possible to combine this procedure with other procedures in face areas such as fat pad removal, temporal SMAS lift, S-lift, platysmaplasty, skin resurfacing, fat reduction/augmentation, rhinoplasty, etc. The technique of "Lower SMAS-platysma face lift using hidden incisions in the earlobe fold" provides the author with a safe alternative in comparison with face lifts using preauricular skin incisions and elevation, platysmal and subplatysmal flaps and SMAS dissections, submental surgery, deep plane or composit face lifts.

THE IDEA

Ptosis and laxity of the "facial mask" in the lower face and neck are well known to be the first signs of ageing. The idea of the lower SMAS-platysma face-lift is to tighten and elevate the lower face and neck, together with their most important elements, because soft tissue and skin are attached to the SMAS (Fig.2). Loose SMAS and skin laxity give face a heavy, hanging, sad and tired expression. Where no visible ptosis exists - especially in young patients - heavy faces, not well-expressed cheekbones, bad proportions and angles enhance a sad look that can be corrected (Fig. 3).

The idea of this lower SMAS-platysma face lift with hidden incisions in the retro-lobular fold gives the answer on how to re-structure and re-position the face and its elements in the lower part without visible pre-auricular and retro-auricular scars. All well-known traditional, SMAS, deep, etc. face lifts can not avoid visible scars and an "operated-on" appearance, due to skin and SMAS rotation and pull.

The only place to hide the incisions and at the same time to have the best approach to the cheek SMAS and platysma in a radius of a min of 3 cm from the tragus is the fold behind the earlobe. It normally permits a 1.5 cm long incision that is enough to work in the pre-auricular zone: to elevate (not dissect) pre-auricular SMAS and retromandibular platysma into the skin incision line and to suture them to the mastoid (Fig. 1).

Fixing SMAS in a better position aims repositioning of other soft tissue facial structures as well. Changing the position of SMAS restores the aesthetic angles, shape and proportions as a basis for beautification and rejuvenation and gives a happy, youthful appearance and a smiling expression not only to the elderly. In young patients the aim of lower SMAS lift is beautification based on facial aesthetics and first of all: cheekbone beautification with concave shaping of the so-called "hungry cheeks" - much loved by any individual (Fig. 3, 5). Shaping the submandibular space is another aim of the lower SMAS-platysma lift.
Fig. 1. Operative technique of lower SMAS lift. Retrolobular approach. The subSMAS bite of the cheek SMAS is fixed to the mastoid. The subplatysmal bite of the retromandibular platysma is fixed to the mastoid as well.

Fig. 2a, b. Before and after lower SMAS-platysma lift. The skin attached to the SMAS is lifted as well. Rejuvenation in an elderly patient.

DEFINITION

"Lower SMAS-platysma tightening" or "duplication" using nonabsorbable sutures to fix and lift the SMAS including platysma to the mastoid. The approach is an incision in the fold behind the earlobe.

AIM

In our face lifting technique, the primary goal is to reposition the loose "fascial facial mask" - the SMAS, including platysma for the purpose of refreshing facial appearance and obtaining beautification, corresponding to aesthetic angles and proportions and anatomic position of youth. It may also be used for sculpturing the jaw line (Fig. 2-6), softening the nasolabial groove (Fig. 2 - 6), and beautification in minor jawling or submental laxity and in cases of early or medium facial ptosis (Fig. 2-6). It is very important to answer optimally patient's requirements for immediate beautification and return to work avoiding scars and long recovery period (Fig. 3, 5)

To this aim, lower SMAS and platysma are blunt dissected from the skin, and by pulling them into the skin incision line, they are duplicated and securely sutured to stabile structures. This technique is quicker and safer than SMAS undermining, partially excising, folding on itself and sewing down in new position and changed angles that may lead to a palpable or visible fold in mimics - for example while smiling. The author's technique is a plication technique: SMAS and platysma are pulled in normal directions behind the earlobe and sewn down to stable structures. This technique obtains a normal aesthetic "non-operated" appearance to the operated face without scars and covers totally patient's expectation (Fig 2-5).

Beautification and immediate social activity is the main aim that has been made possible by this technique and these are the first and most important patient's requirements.


Fig. 3a, b. Before and immediately after lower SMAS-platysma lift. Minor ptosis and jaw line are corrected. A small bandage stays for an hour or two. The patient returns to work.

ANATOMY

The SMAS is a fibro-muscular layer that connects the platysma and frontalis and acts as a suspension for the overlying facial skin. It lies deep to the subdermal plexus of vessels and superficial to the motor nerves of the facial musculature. It provides a suspensory sheet, which distributes forces of facial expression. The idea that suspending this layer leads to a better long-term suspension of the overlying skin has become common [1,2,3].

When face droops with age, due to the pull of gravity on the fascia and the loosening of facial ligaments, the face has to be restored first of all by tightening the "fascial facial mask" - the SMAS including platysma. Jowling, for instance, is caused in the first place by displacement of the SMAS [4-7]. Another area that should be mentioned in relation to rhytidectomy is the neck. One of the causes of visible facial aging is the sagging neck.

The SMAS is well defined under the zygomatic arch as the parotid masseteric fascia. It continues inferiorly as the superficial cervical fascia and represents the aponeurotic connection between the mimetic musculature and the overlying skin [1,2].

The continuity between the aponeurotic facial fascia and the platysma is an anatomical fact, useful in performing face-lift surgery. The SMAS overlying the parotid gland and malar eminence tends to be substantial and easy to handle, because the parotid and zygomaticus major and minor muscles protect the underlying facial nerve branches. With respect to protecting the facial nerve structures, we can accept that the lower SMAS-platysma face-lift is done in a very secure area.

SURGICAL TECHNIQUE

This ambulatory operation takes about 10 min for each side and is normally done under local anesthesia: infiltration of the retro-lobular fold and the pre-lobular subcutaneous area of 3 cm in front of the tragus and the earlobe. Similar infiltration is done in a radius not more than 3 cm from the lobule in direction to the platysma retro-mandibular. Blunt dissection is made in a radius of 3 cm from the earlobe in the direction of the lateral oral cantus and the chin as well as of the retro- and sub-mandibular area. After dissection, cheek SMAS and platysma are separately tied with non-absorbable sutures to the mastoid. On the other side, cheek and platysma SMAS are sutured in a similar fashion. In this manner the lower SMAS lift is developed from the preauricular SMAS (at the level of the earlobe) and the retro-mandibular platysma, attached posteriorly over the mastoid process. Tension is applied, and these structures are secured with nonabsorbable sutures to the mastoid fascia, providing a cheek SMAS backward & upward lift and platysma upward lift (Fig. 1). Skin is closed in one layer. Gauze dressings are not obligatory but can be put overnight or for several hours only (Fig. 3). Sutures are removed in 3-7 days.

RESULTS

175 patients have been operated in the last 4 years. Neither bruising, nor haematomas, nor infections have been observed. The soft swelling around the earlobe is invisible for other observers and stays for some days. The moderate tension on the face usually gives a pleasant feeling that lasts for some hours or days. In one patient, an upper lid ptosis occurred during fixation of the pre-auricular SMAS; immediate release of the suture removed this "complication" immediatelly. In one 63 years old patient, in line with her aesthetic requirements, an additional pre-auricular skin excision (S-lift) was performed; due to the previous SMAS tightening it was not possible to excise more than 2 to 3 mm skin in front of the ear. No other complications or complaints have been observed in this period. Scarring of the skin in the fold behind the earlobe is nearly invisible, also due to the lack of tension on the skin. Results in these cases are optimal: there are no limitations to postoperative activities; no "operated-on" appearance, no visible scars, and no signs of operative intervention (Fig 2-5).

The lower SMAS lift gives a harmonious and strong lifting of the lower third of the face and creates an acute cervicofacial angle. It achieves a bidirectional lower face and neck lift, soft correction of the nasolabial fold and correction of submental area laxity. It is also possible to combine this procedure with other procedures such as fat pad removal, temporal SMAS lift, S-lift, platysmaplasty, skin resurfacing, fat reduction/augmentation, rhinoplasty, etc. Only a small number of patients need additional sewing together of the platysma in the midline. In most cases, the ultrasonic assisted liposuction is enough to enhance a good angle of the neck (Fig. 6). In our patients the lower SMAS-platysma lift is usually combined with a "Temporal SMAS lift by minimal hidden incisions" [20] in order to obtain a "Total SMAS lift" (Fig. 2). Generally, SMAS lifts by minimal hidden incisions are nice ambulatory weekend procedures done separately or jointly. On the one hand, the "Temporal SMAS lift" changes the expression; gives a pleasing beautification and rejuvenation of the skin, eyes, brows, and cheekbones. On the other, the lower SMAS lift gives a very good rejuvenation of the "subzygomatic" cheeks, jowls and submental area.

Fig. 4a, b. Before and immediate result after Lower SMAS-platysma lift, Ultrasonic assisted liposuction of the neck and Columella sliding rhinoplasty. No signs of the operations are visible.


Fig. 5a, b. Before and after lower SMAS-platysma lift. A. Thin and loose skin in the lower face. Gravity on soft tissue and skin is visible in different positions. B. The SMAS and attached to the SMAS soft tissue and skin are tightened. No gravity signs on the soft tissue and skin are visible - in any position. Lovely youthful "hungry cheeks" pleased the patient.

Fig. 6a, b. Effect on the folds in t hat area in a 53 years old patient.

COMPLICATIONS

As described in "Results", some minimal problems have occurred in the operated patients over the past four years.

The author's experience with the lower SMAS-platysma facelift indicates that the operation can be performed safely with a minimum complication and maximum patient's satisfaction.

Injury to the facial nerve in rhytidectomy in the literature has been described in less than one percent of the cases, and a spontaneous return of function in more than 80 percent of these injuries results within 6 months [8,9]. With the introduction of the new author's technique without aggressive platysmal and subplatysmal flaps and SMAS dissections, the risk of injury to facial nerve branches is decreased significantly. Nevertheless, surgeons have to actively supervise patient's reactions for signs of facial palsy during operation.

DISCUSSION

Stretching the skin solely is obsolete. The difference between a SMAS, extended SMAS and deep plane, sub-periostial facelifts is mostly presented in the number of complications, which include haematoma, pixie ear, nerve injury, and skin slough [10-15]. Deep-plane and composite techniques achieve a deeper suspension which some feel lead to a more permanent result [16,17]. The risk of facial nerve injury is higher [8,9]. Postoperative care is longer and preauricular incisions are not patient's best choice nowadays.

The "classic" rhytidectomy was essentially a large rotation-advancement skin flap. Then the superficial muscle-aponeurotic system, or SMAS, was described by Mitz and Peyronie in 1976 [1]. This gave rise to the development of the SMAS face lift that has been the golden standard for many years. In the 90's Hamra developed the deep-plane and composite rhytidectomies [17,18]. These alternatives could not surpass the SMAS lift as the standard operation to which others are compared.

Two techniques of SMAS lift are possible, in which: 1) the SMAS is undermined, partially excised, and sewn down in its new position, and 2) the plication technique, in which undermining is not undertaken but the SMAS is instead pulled up and sewn down [10-15].

The author employs sutures running from the platysma and cheek SMAS back to the mastoid fascia using hidden minimal incisions. The SMAS sutures are used to obtain and preserve a more youthful low face and neck. The technique of "Lower SMAS-platysma face lift using hidden incisions in the earlobe fold" provides the author with a safe alternative in comparison to face lifts using preauricular skin incisions and elevation, platysmal and subplatysmal flaps and SMAS dissections, submental surgery, deep plane or composit face lifts.

CONCLUSIONS

The "Lower SMAS lift by hidden retro-lobular approach" provides a safe and effective ambulatory method for beautification as well as for rejuvenation of the early sagging face, as an independent procedure or in combinations, in order to solve problems of the face and the neck. This "sub-zygomatic" SMAS lift is part of the beautification surgery methods on the face. It is a safe and effective method for lifting the jowl and platysma SMAS. It addresses problems of jowling or submental laxity. This much desirable effect on the face is immediate, without visible scars and which fulfills patient's desires.

REFERENCES

1. Mitz V, Peyronie M. The superficial musculo-aponeurotic system (SMAS) in the parotid and cheek area. Plast Reconstr Surg 58: 80-88, 1976.
2. Jost G, Lamouche G. SMAS in rhytidectomy. Aesthetic Plast Surg 2: 69-74, 1982
3. Larabee WF, Makielski KH, Cupp C. Facelift anatomy. Facial Plastic Surgery Clinics of North America 1(2): 135-52, 1993.
4. Brennan HG. Rhytidectomy: Mandibular and submandibular contouring. Facial Plastic Surgery Clinics of North America 1(2): 181-96, 1993.
5. Kridell RWH, Covello LV. The aging face (rhytidectomy). In BJ Bailey (ed.): Head & Neck Surgery - Otolaryngology, 2nd edition. Lippincott - Raven, 1998, pp. 2693-716.
6. Berman WE. Rhytidectomy. In CJ Krause (ed.) Aesthetic Facial Surgery. Lippincott, 1991, pp 513-31.
7. Dedo DD. The aging neck. In BJ Bailey (ed.): Head & Neck Surgery - Otolaryngology, 2nd edition. Lippincott - Raven, 1998, pp. 2717-32.
8. Baker DC, Conley J. Avoiding facial nerve injuries in rhytidectomy. Anatomical variations and pitfalls. Plast Reconstr Surg 6: 781-95, 1979
9. Seckel BR. Facial Danger Zones: Avoiding Nerve Injury in Facial Plastic Surgery. Quality Medical Publishing, St. Louis, 1994.
10. Webster RC, Smith RC, Papsidero MJ, et al. Comparison of SMAS plication with SMAS imbrication in face lifting. Laryngoscope 92: 901-12, 1982.
11. Lewis JR. Multiple-tiered deep support of cheeks in meloplasty and rhytidectomy. Aesthetic Plast Surg 1: 21-5, 1983
12. Owsley JQ. SMAS-platysma facelift. A bidirectional cervicofacial rhytidectomy. Clin Plast Surg 3: 429-401, 1983
13. Randall P,Skiles MS. The "SMAS sling": an additional fixation in face lift surgery. Ann Plast Surg 1:5-9, 1984
14. Webster RC, Smith RC, Smith KF. Face lift, Part 4: Use of superficial musculoaponeurotic system suspending sutures. Head Neck Surg 3: 780-91,1984
15. McCoullough EG, Perkins SW, Langsdon PR. SASMAS suspension rhytidectomy. Arch Otolaryngol Head Neck Surg 115: 228-34, 1989.
16. Hamra ST. The deep-plane rhytidectomy. Plast Reconstr Surg 86: 53-61, 1990.
17. Hamra ST. Composite rhytidectomy. Plast Reconstr Surg 90:1-13, 1992.
18. Ramirez OM. The subperiosteal rhytidectomy: The third-generation facelift. Ann Plast Surg 28: 218-232, 1992.
19. Beeson WH. Extended posterior rhytidectomy. Facial Plastic Surgery Clinics of North America 1(2): 197-216, 1993.
20. Serdev NS. Ambulatory temporal SMAS lift using minimal hidden incisions. IJACBS, 1(2):17-24, 2001.

 
 
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