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 IJCS / Year: 2001 / Volume 1 - Number 4 / Original Papers
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Head of the 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


The idea of lower superficial muscle-aponeurotic system - SMAS face lift by sutures through skin punctures only or by hidden incisions in the retro-lobular fold gives the answer how to re-structure and re-position the face and facial elements in it’s lower part and neck without visible pre- and retro-auricular scars. The author uses specially designed curved elastic needles as well as semi-elastic long-term absorbable polycaproamide (Polycon) thread No2.

In the first method, the author uses skin punctures only to introduce the needle and the thread, to bite, lift, and fix loose SMAS to stable structures like periosteum or fascia without undermining. Colli fascia, mastoid or occipital periosteum are used as anchor points to fix the cheek and platysma SMAS higher and to obtain lower face lifting.

In the second method, the author uses limited undermining. In this method the fold behind the earlobe is the only place to hide the incision and at the same time to have the best approach to the cheek and platysma SMAS in a distance of 3-4 cm from the tragus. Usually it permits a 1.5-2.5 cm long incision. In this way, changing the position of check and platysma SMAS restores aesthetic angles, shape and proportions and is a base for beautification and rejuvenation not only to elderly. In young patients the aim of SMAS lift should be beautification only, based on face aesthetics.


Ptosis and laxity of the “sub dermal facial mask”- the SMAS in lower face and neck reflects in appearance of ageing signs in the lower face. The idea of the lower SMAS-platysma face-lift using semi-elastic long term absorbable sutures is to tighten and elevate the lower face and neck, together with facial soft tissue without unnecessary incisions. In view of the fact that soft tissue and skin are attached to the SMAS, lifting and fixing the SMAS in better position, aims repositioning of other soft tissue facial structures as well. Loose SMAS and skin laxity give face a heavy, hanging, sad and tired expression. In young patients where no real ptosis exists, heavy faces, not well-expressed cheekbones, bad proportions and angles, sad look, should be corrected.

The idea of this specific lower cheek and platysma SMAS face lift is to achieve immediate result and to avoid trauma, visible pre- and retro-auricular incisions, excisions, and scars. Well-known, traditional SMAS, deep and other face lifts can not avoid some visible scars or "operated-on" appearance, due to skin and SMAS rotation and pull.


The two methods, described by the author, represent lower cheek and platysma SMAS “tightening" or “duplication” using elastic long-term absorbable sutures, needle perforations only, or hidden retro-lobular incision, where cheek and platysma SMAS are lifted and fixed to the colli fascia, mastoid, or occipital periosteum.


In our lower face lifting technique, the primary goal is the repositioning of the sub dermal facial mask - the SMAS in view of refreshing of the facial appearance and obtaining beautification, corresponding to aesthetic angles, proportions and anatomic position of the youth. It is used for sculpturing of jaw line, softening of nasolabial fold, and beautification, mostly in minor and medium jowling, submental laxity and is best in cases of beautification, early or medium facial ptosis. In cosmetic surgery, it is very important to answer patient’s requirements for immediate beautification, to avoid visible scars, as well as to give them the chance to return fast to social life and work without long recovery period.

For this aim, author’s methods are created to be minimally invasive, without trauma


Face droops with age, due to gravity, atrophy and loosening of the facial ligaments. Jawing is caused by displacement of the SMAS and ageing of the skin [4-7]. The neck is a face related area. The sagging neck is an important part of the aging face.

The SMAS is a fibro-muscular layer that connects platysma and galea and acts as a suspension for the overlying facial skin. The continuity between the aponeurotic facial fascia and the platysma is an anatomical fact, useful in performing face-lift surgery.
Subdermal plexus of vessels are superficial to SMAS. Motor nerves and facial muscules lie deep to SMAS. SMAS provides a suspensory sheet, which distributes the forces of facial expression. The idea that lifting this layer leads to better long-term suspension of overlying skin has become common [1,2,3].

SMAS is well defined under the zygomatic arch as parotid-maseteric fascia. It continues inferiorly towards the superficial cervical fascia and platysma and represents aponeurotic connections between mimetic musculature and overlying skin [1,2].

SMAS overlies the parotid gland in mandibular angle and tends to be substantial and easy to handle, because the parotid gland, zygomaticus major and minor muscles protect underlying facial nerve branches. With regard to protecting the facial nerve structures, we can accept that lower SMAS-platysma face-lift “by sutures only” or “with retro-lobular incision” is done in a fairly secure area.


The scarless lower SMAS-platysma face-lift by sutures, using skin perforations only or hidden retro-lobular incision is an ambulatory operation that takes about 10 min each side and is done under local anaesthesia.


The points of skin perforations and fixation to colli fascia, mastoid or occipital periosteum should be planned previously. Infiltration of selected areas and skin punctures at the planed points are done. The needle is introduced through the planed skin perforation, than through colli fascia or even better through mastoid or occipital periosteum and follows the plan: first through the colli fascia and after that through the cheek-SMAS by perforating both of them using zigzag tip movement to sow them as a “harmonica”. Attention should be paid when introducing the needle tip through the cheek-SMAS - the parotid gland lies below the SMAS. Damaging of parotid should be avoided. The needle tip is fed with the thread and is pulled out through the needle pass. The second parallel needle pass goes through the same skin perforations and tissue plan. The second end of the thread is pulled out through the second needle pass. The knot is made under medium elastic tension. Possible skin dimples can be managed by pulling the skin laterally and away from the suture, using one of the of the “mosquito” instrument’s branches. Thus, the first suture of cheek-SMAS fixation to mastoid (or to colli fascia, or to occipital periosteum) is fulfilled. In the same manner the second suture is done, using a separate skin perforation for platysma bite and lift to a previously planed point for fixation (Fig. 1). Attention should be paid to superficial vessels as well as to the internal jugularis vein and artery, passing under the sterno-cleido-mastiod muscle

On the other side, the sutures are placed in the same way.

A.     B.     C.    
D.     E.     F.    
G.     H.     I.    

Fig. 1a, b, c, d., e., f., g., h., i.  A. Lidocain infiltration of the mastoid periosteum, colli fascia and the cheek-SMAS, B. Scalpel blade No 11skin perforation in the selected points, C. The needle is introduced through the skin perforation, than through the mastoid, colli fascia and cheek-SMAS, D. The thread is introduced through the needle pass, E. Second pass of the needle following the same plan, F. the second end of the thread is introduced through the second needle pass, G. The pull of the thread lifts the cheek SMAS, H., I. Skin dimpling has been removed by releasing the skin from attachments using a branch of a “mosquito” instrument.

A.     B.     C.    
D.     E.     F.    

Fig. 2a, b, c, d., e., f., g.  A. The needle is introduced through the skin perforation, than through the mastoid, colli fascia and platysma-SMAS, B. The thread is introduced through the needle pass, C. Second pass of the needle following the same plan, D. the second end of the thread is introduced through the second needle pass and the pull of the thread lifts the platysma-SMAS E., F. Skin dimpling should be removed by releasing the skin from attachments using a branch of a “mosquito” instrument, G. The knot is made and the result is immediately visible.


The only place to hide the incisions, and at the same time to have a very good approach to cheek SMAS and platysma in a distance of 3-4 cm from the tragus, is the fold behind the earlobe. It usually permits a 1.5-2,5 cm long incision, which is enough to elevate pre-auricular SMAS and retromandibular platysma into the skin incision line and to suture them to the mastoid.

Local anaesthesia infiltration is done in the retro-lobular fold, 3-4 cm in front of tragus and retro-mandibularly, in direction to platysma. Incision is done and a blunt subcutaneous undermining is performed through the retro-lobular opening in a radius of 3-4 cm from the earlobe in direction to: the oral commissure, chin, sub- and retro-mandibular area. After undermining, cheek SMAS and platysma are separately caught with a “mosquito” instrument, pulled out in portions into the wound opening and sutured with polycaproamide No 2 sutures to colli fascia and 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, and attached posteriorly over the mastoid process. Medium elastic tension is applied, 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 used overnight or for some hours. Sutures are removed in 3 to 7 days.

   Fig.3 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.

A.     B.     C.    

Fig. 4a, b, c, d. A. After Lidocain infiltration, retrolobular incision and about 3 cm blunt dissection of the preauricular and subauricular zones, the cheek-SMAS is fixed with a "Mosquito" instrument and pulled out into the opening of the retrolobular incision and stitched. B. A stitch to the mastoid is done. The suture of the pulled SMAS towards the Mastoid realizes the SMAS lift. C. Closure of the retroauricular incision

This technique is quicker and safer than SMAS undermining, partially excising, folding on itself and sewing down in new position and changing angles that may lead to a palpable or visible fold in mimics – for example while smiling. The author’s technique is a tightening or plication technique: SMAS and platysma are pulled in normal directions behind the earlobe and sown 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.

It is also possible to combine lower SMAS lift with other procedures such as fat pad removal, platysma suturing, skin resurfacing, fat reduction/augmentation, rhinoplasty, etc. Only a small number of patients need additional platysma sewing in the midline. In double chin cases most important is to remove the fat collection. In authors hands, ultrasonic assisted liposuction is enough good in such cases to enhance a good angle of the neck and to tighten the skin.

The method consists of 4 important steps:


240 patients have been operated with Method I during the period November 1994-May 2001. Method II was performed in 180 patients in the last 4 years. The results in these cases are immediate and optimal: there are no limitations to postoperative activities; no "operated-on" appearance, no visible scars, and no signs of operative intervention (Fig 3-7). Moderate tension on face gives usually a pleasant feeling that lasts for some hours or days. Neither haematomas, nor infections have been observed. Bruising is rare.


In method I, in very loose skin cases, it is possible to obtain a bulging effect at the sterno-cleido-mastoid site that adapts and disappears in 5 to 7 days. In method II there is no bulging or folding, but a soft swelling around the earlobe that is invisible for other observers and stays for some days.

In method I, the skin punctures disappear in 2-3 days. In method II, the skin scar in the fold behind the earlobe is invisible, due to lack of skin tension as well.


Fig.5 Visible change in the lower face appearance after a brow lift and lower SMAS lift by sutures with skin punctures only.


Fig.6 Immediate result in the OP theatre. Immediate and total change in the lower face after a brow lift and a lower SMAS lift using sutures with skin punctures only


Fig.7 Total face beautification: Temporal SMAS, Lower SMAS lift using sutures with skin punctures only, and Rhinoplasty. The change pleases the patient. Rejuvenation of the lower face.

A.     B.     C.    

Fig.8 a, b, c. Fig. 8. a, b, c., A. Before, B. Immediately after simultaneous temporal, medial and lower SMAS face lift by sutures using skin punctures only, brow lift by sutures, rhinoplasty, and lip augmentation. C. 3 days after surgery.

D.     E.     F.     G.    

Fig.9 d, e, f, g. D. Same patient before, E. In the op-theater, immediately after simultaneous temporal, medial and lower SMAS face lift by sutures using skin punctures only, brow lift by sutures, rhinoplasty, and lip augmentation. Skin punctures for the lower SMAS lift by sutures are visible, F. the day after. Skin punctures nearly invisible. Minimal bruising, G. 3 days after surgery. Skin punctures invisible, still some bruising persists, but make up corrections are recommended. Return to social life is possible.


With method II, in one patient, same side upper lid ptosis occurred during fixation of the pre-auricular SMAS to the colli fascia. Immediate release of the suture solved this “complication” on place and another suture was done without further complications In one 63 years old patient, in line with her aesthetic requirements, an additional pre-auricular skin excision (S-lift) was performed 3 years later; but due to the previous SMAS lift using method II, 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.

A.     B.    

Fig. 11 a, b. A. Before and B. immediately after surgery in an 37 years old patient. A pleasant result in the lower face and jaw line. A small tape bandage stays for hours only. Patients usually return to work in a day or two.

A.     B.    

Fig. 12 a, b. A. Rejuvenation in an elderly patient. The SMAS and the attached to it skin is tightened. A. Before and B. after lower check and platysma SMAS lift with retro-lobular incisions. Very good result with skin beautification. The effect on the skin depends on the attachments to the SMAS, which is lifted.

A.     B.    
C.     D.    
E.     F.    

Fig. 13 a, b, c, d, e, f. Before and the day after lower SMAS face lift with retro-lobular incisions in a 40 years old man, and columella sliding rhinoplasty. No signs of the operations are visible next day.

A.     B.    

Fig. 14 a, b. Before and after lower SMAS-platysma lift with retro-lobular incisions in a 37 years old female patient. A. Thin and loose skin in the lower face. Gravity on soft tissue and skin is visible in different positions. B. The SMAS and the attached to it soft tissues and skin are tightened. No gravity signs on the soft tissue and skin are visible in any position after surgery. Lovely tightened youthful “hungry cheeks” please the patient.

A.     B.    

Fig. 15 a, b. Effect on the nasolabial and marionette folds in a 53 years old patient one day after lower SMAS lift, rhinoplasty and allar base narrowing.


Minimal problems have occurred in some of our patients. As described above one case of taking a facial nerve branch in the suture during performing method II led to ptosis of the upper lid and was solved immediately by removing of the suture. It is a rare complication, because the facial nerve runs a bit higher, just below the tragus and immediately after that penetrates deep into parotid gland. In method II, we have to prevent dissection or placing the suture too high, and should observe patient’s status during the operation.

In method I, the needle penetrates the tissue much lower and we have had no cases of facial nerve insertion into the knot. Three patients described some loss of sensation in the ear lobe for a couple of weeks. That happens if fixing the great auricular nerve within the suture. The great auricular nerve runs about 1 cm behind the ear lobe, fixed to colli fascia. The trauma of involving the nerve into the knot provoked by a lateral traction adapts in some weeks. Swelling and bruising are rare.


Beautification and immediate social activity are the first and most important patient’s requirements. This main aim of cosmetic surgery has become possible using these two techniques.

The author's experience indicates that these specific methods of lower SMAS lift can be performed safely with minimum complications and maximum patient’s satisfaction.

Stretching the skin solely is obsolete. Excision SMAS lifts, extended SMAS lift, deep plane, and sub-periostial face-lifts are presented with number of complications, which includes 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], but 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.

Some techniques of SMAS lift are described, in which: 1) the SMAS is undermined, partially excised, and sown down to a new position, and 2) plication technique with undermining, and 3) plication technique in which undermining is not undertaken but the SMAS is instead pulled up and sewn down [10-15].

Author’s suture methods are performed to obtain and preserve an youthful low face and neck, fixing platysma and cheek SMAS to colli fascia, mastoid, or occipital periosteum. These techniques of “scarless lower SMAS face lift” provide a safe alternative to face lifts using preauricular skin incisions and elevation, platysmal and subplatysmal flaps, SMAS dissections, submental surgery, deep plane or composit face lifts.

Injury to the facial nerve in rhytidectomy has been described in less than one percent of the cases, and a spontaneous return of function results within 6 months in more than 80 percent of these injuries [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, the surgeons have to follow up the patient’s reactions carefully for signs of facial palsy during operation.


The “Scarless lower cheek and platysma SMAS lift by sutures using skin needle perforations only or hidden retro-lobular incision” provides a safe and effective ambulatory method for beautification and rejuvenation of early and medium sagging face. It is an effective method that addresses problems of yowling or submental laxity. Nice and youthful shaped jaw, acute cervicomandibular angle and straightened cervical skin is the most desirable effect. The results fully correspond to patient’s desires. The effect is immediate, without visible scars.

Cheekbone beautification means concave shaping of the so-called “hungry cheeks” - much loved by young people. Outlining the sub-mandibular space is yet another objective of the lower SMAS-platysma lift.

The lower SMAS lift is a bidirectional lower face and neck lift that gives harmonious, strong lifting effect on sub-zygomatic area and jow, and creats acute cervicomandibular angle. It achieves partial correction of the nasolabial folds and submental area laxity. It is possible to combine this procedure with other procedures in other face areas, such as fat pad removal, temporal, and medial SMAS lift, platysma suture, fat liposuction, fat transfer, rhinoplasty, skin resurfacing, etc.

In our patients the lower SMAS-platysma lift is very often combined with temporal SMAS lift and brow lift by sutures [20, ] and/or medial SMAS lift ( ) in order to obtain a “total SMAS lift”. Generally, SMAS lifts by sutures are nice and easy ambulatory weekend procedures.


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.

Address for correspondence:

Nikolay P. Serdev, MD, PhD

Medical Center "Aesthetic Surgery and Aesthetic Medicine"
11, "20th April" St., 1606 Sofia, BULGARIA
Phone (mobile) +359 888 802004
Fax +359 2 9515668
E-mail nserdev@infocom.bg

The Bulgarian Society of Aesthetic Surgery and Aesthetic Medicine

Send for publication: 02 07 2001

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 IJCS / Year: 2001 / Volume 1 - Number 4 / Original Papers
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