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
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.
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.
"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.
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
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.
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
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.
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.
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
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
SMAS lift by minimal hidden incisions"  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
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
Fig. 6a, b. Effect on
the folds in t hat area in a 53 years old patient.
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.
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 . 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.
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.
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with SMAS imbrication in face lifting. Laryngoscope 92: 901-12, 1982.
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