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 IJCS / Year: 2002 / Volume 2 - Number 4 / Original Papers
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Title: SERDEV SUTURE METHOD FOR AMBULATORY MEDIAL SMAS FACE LIFT
Nikolay P. Serdev, M.D., Ph.D.
Pages: 1 - 13/
 
 

SERDEV SUTURE METHOD FOR AMBULATORY MEDIAL SMAS FACE LIFT

Nikolay P. Serdev, M.D., Ph.D.

Head of Aesthetic Surgery and Aesthetic Medicine Medical Center - 11 “20th April” St., 1606 Sofia, BULGARIA

President of the Bulgarian Society of Aesthetic Surgery and Aesthetic Medicine

SUMMARY

Serdev suture techniques lift the SMAS, attaching it to stable non-movable temporalis fascia or zygoma periosteum. It effects in lifting of fat pad at the level of zygomatic bone, restoring cheek-bone area, giving volume and higher reposition of the cheek-bone, and youthfully elongating “beauty triangle”. For this reason the author uses special curved semi-blind and semi-elastic needles of different lengths with hollow tip to introduce long term absorbable, semi-elastic, braided, antimicrobial Bulgarian polycaproamide (Polycon) threads No2.

Medial lift using Serdev suture methods is ambulatory, under local anaesthesia, very well tolerated by patients, with immediate effect, with extremely short post operative period, fast recovery and nearly immediate return to social life. Complications are under 0,004% and patient’s satisfaction is extremely high, especially aesthetic one.


HISTORY

Two methods of facial SMAS lift exist: 1.the SMAS is undermined, partially excised, and sewn down in its new position, and 2. the placation technique, in which undermining is not undertaken but the SMAS is instead pulled up and sewn down. The latter technique is quicker and safer, but it may leave a palpable fold for a while1. “Serdev suture”2-12 techniques lift the SMAS and fix it to stable non-movable anatomical structures, such as temporalis fascia or periosteum. Local anaesthesia with i.v. sedation is used versus general anaesthesia due to shorten time of intervention, surgeon and patient preference13. 14. Earliest operations were inherently removing area of skin at the hairline15. The "classic" rhytidectomy developed into a large rotation-advancement skin flap. Then in 1976 the superficial muscle-aponeurotic system, or SMAS, was described by Mitz and Peyronie16. The SMAS facelift became the gold standard17-18.. In 1990’s sub-fascial, tri-plane, deep-plane, composite, subperiosteal, multiplane, “en-bloc” and other extended surgical methods for rhytidectomy were made popular19-28. Nowadays lesser operations, reduced risks and faster recovery time became common, but SMAS lifts without undermining remain the best long-term suspension of the overlying skin1-14.


ANATOMY

The fibro-muscular layer described as Superficial Muscle Aponeurotic System (SMAS) connects the vertex and platysma and acts as a suspension for the overlying facial skin. The SMAS is fixed to the zygoma by the perpendicular zygomatic SMAS extension that limits the facial SMAS movement and the pull on the temporal SMAS upwards16-18, 29. Facial SMAS lies superficial to motor nerves of facial musculature and deep to sub-dermal vessels. It represents the aponeurotic connection between the mimetic musculature and the overlying skin as a suspensory sheet which distributes muscle forces into facial expressions. Under zygomatic arch SMAS is defined as parotid maseteric fascia and inferiorly as superficial cervical fascia30.

Over zygoma, movable SMAS lies superficial to stable and non-movable temporalis fascia. In direction to zygoma, at superior orbital rim level, temporalis fascia splits in two: superficial and deep layer of temporalis fascia. These two fascial layers enclose fat pad – intermediate fat pad - and within: frontal branches of facial nerve, artery and vein. As anatomic landmark of this surgical danger zone – frontal branch of facial nerve is considered to cross zygomatic bone traveling along a line connecting tragus base to a point 1.5cm above eyebrow30-31 (Fig. 1). Middle temporal artery, which arises from superficial temporal artery at the level of the arch, enters temporalis fascia immediately above zygomatic arch, supplies fascia and intermediate temporal fat pad, and gives off branches to temporalis muscle itself. A filament from zygomatic branch of maxillary nerve also travels within intermediate fat pad16-18, 29-31.

So, anatomic topography forms a quadrangle 2 cm in front of tragus and 2 cm above zygomatic bone that can be described as danger area, if deeper than the superficial layer of the temporalis fascia, where facial nerve can be injured due to a lot of variations.

A. B.

Fig. 1. Intermediate fat pad and facial nerve branch



THE IDEA OF MEDIAL FACE LIFT BY SUTURES without skin incisions and excisions

It was created to lift loose medial SMAS (zygtomatic SMAS extension, fat pad fascia, parotid maseteric fascia) and to fix it to stable zygomatic periosteum or superficial layer of temporalis fascia. It effects in lifting of fat pad at the level of zygomatic bone, restoring cheek-bone area, giving volume and higher reposition of the cheek-bone, and youthfully elongating “beauty triangle”. For this reason we use special curved semi-blind and semi-elastic needles of different lengths with hollow tip (Fig. 2) to introduce long term absorbable, semi-elastic, braided, antimicrobial Bulgarian polycaproamide (Polycon) threads No2 (Fig. 3).



Fig. 2. Curved semi-blind and semi-elastic needles of different lengths with hollow tip



Fig. 3. Long term absorbable (2 – 3 years), semi-elastic, braided, antimicrobial Bulgarian polycaproamide (Polycon) threads


SURGICAL METHODS

For any of that medial SMAS lifts we use 2 or 3 skin perforations to introduce the needle and to place the tread in the necessary anatomical level such as fascia or bone periosteum) (FIG. 4).



Fig. 4. Perforation and fixation points


FIXATION POINTS TO ZYGOMA AND TEMPORALIS FASCIA (Fig. 4)

Point A. Fixation point to superficial layer of temporalis fascia: At lower medial angle of hairline. This point has to be 1 cm anteriorly to presumable trace of facial nerve frontal branch, i.e. min 2 cm anteriorly from the tragus;

Point A1 and A2. Fixation points to the zygoma: At the zygomatic bone line in a selected distance min 2 cm anteriorly from tragus.

Preferred point to catch the bone periosteum is Point.A2 - 1 cm below the lateral cantus of the eye to catch zygomatic periosteum


SMAS FIXATION POINTS (Fig. 4)

Point B. For cephalic-posterior traction in young patients: 2-3 mm laterally from nasolabial fold, at its upper end, exactly lateral from nostril in skin or inside in nostril mucosa in same area. NB: To protect thread from nostril mucosa we use plastic cannullas with 2 end openings, for example made from a needle cap with cuted blind end (Fig; 8).

Point B1. In case of more expressed nasolabial fold in young or mid aged patients at middle or lower point at nasolabial fold; lower than nostril; 2-3mm laterally from nasolabial fold

Point C. In elderly just lateral from the oral commissure (angulus oris).

Point D. Smile dimple point. For cephalic traction of the jowl hangings and fat pat hanging in elderly: A little bit lower than the cross point of a line connecting oral commissure with tragus and perpendicular line of eye lateral cantus line.


TYPE of TRACTION on SMAS, FAT PAD and IT FASCIAS

A lot of possible tractions on the fascial system of the middle face are possible using the mentioned perforation and fixation points:

TYPE I. Traction on SMAS zygomatic extension;

TYPE II. Combined traction on zygomatic extension of SMAS and fat pad and it fascias;

TYPE III.Traction on fat pad and it fascias with or without cheek dimple;

TYPE IV.Traction on Cheek SMAS;

TYPE V. Traction on Cheek SMAS and fat pad incl. it fascias;

TYPE VI. Traction on Cheek SMAS and fat pad incl. it fascias with or without cheek dimple;

TYPE VII.Cheek dimple only

etc.

TYPE I. TRACTION ON SMAS ZYGOMATIC EXTENSION:

Using 2 perforation points:

1st step – superior pass Variant I: Skin perforation

  • Semi-sharp curved needle is introduced in point A. at lower medial angle of hairline in anterior direction following upper curve of zygomatic bone; the pass in that first 1cm is superficial, biting superficial layer of temporalis fascia.(deeper bite can injure frontal nerve branch or vessels, situated in intermediate fat) (Fig 1); after that needle bites zygomatic periosteum at a distance min 2 cm from the tragus; after that needle passes medium deep in soft tissue following upper curve of zygomatic bone and going out through skin perforation in point B at nostril angle. Thread is introduced in needle tip hole and first thread end is pulled out through both perforation points.
    1st step – superior pass variant II: Transmucosal pass: 2nd point B is done inside lateral nostril. Thread should be protected from nostril mucosa using a cannula (to prevent contamination of the thread – Fig. 8)

    2nd step – inferior pass:

  • Needle is introduced through first temporal skin perforation point A in lower-anterior direction below zygoma; in first 1cm bite is superficial (deeper bite can injure frontal branch nerve or vessels, situated in intermediate fat); after that needle passes medium deep in soft tissue following lower curve of zygomatic bone and going out through perforation point B in skin or trans-mucosal. Second end of thread is introduced in needle tip hole and is pulled out through both perforation points.
    Thread circle around zygoma and zygomatic SMAS extension now is done and knot is made under medium tension (strenuous tension hurts tissue and can be a cause for postoperative problems). Pull on SMAS zygomatic extension and lifting is done in a temporal direction with a stable fixation to superficial layer of temporalis fascia and/or to zygomatic periosteum). Soft tissue amount inside of thread circle makes cheek-bone volume and prominence. Brighter distance between 2 parallel thread passes augments cheek bone that could be desired.

    Any other step order is possible to facilitate surgeons work and to obtain desired result.

    Skin and tissue impressions at perforation points are released from the suture by skin pull using a “mosquito” instrument branch.

    A. B. C.

    Fig. 5. Traction on the zygomatic extension of SMAS: A. Puncture drawing, B. Before; C. 4 days after trans-mucosal medial lift and simultaneous brow lift by suture

    Pulling the zygomatic extension of SMAS flattens the nasolabial fold and the zygomatic area becomes more expressed. in higher position, eliminating the nasolabial and second fold. The effect to the lower cheek is forming of a nice young looking “hungry” cheek.


    TYPE II. COMBINED TRACTION ON SMAS ZYGOMATIC EXTENSION AND FAT PAD FASCIAS.

    Distance between 2 thread parallel passes – superior and inferior - can be different bright and will produce different augmentation of the cheek bone area.

    Using 3 perforation points (in elderly or in cases of much consumed cheek-bone area soft tissue):

    A. B. C.

    Fig. 6. Combined traction on SMAS zygomatic extension and fat pad fascias. A. Puncture drawing, B. Before, C. After medial SMAS lift. New cheek bone volume is obtained; nasolabial, second and marionette folds are managed; lower lid is changed visually.

    We use first perforation point A, second skin or mucosal point B, and third skin or mucosal perforation point C. The pass between the 2nd and 3rd perforation point (B. and C.) is located centrally in fat pat deepness (Fig. 7).



    Fig. 7. Combined traction on SMAS zygomatic extension and fat pad fascias. Pass between 2nd and 3rd perforation point B. and C.

    Using mucosal perforation points: 2nd point B. is done inside lateral nostril and 3rd point C. in oral mucosa at lower nasolabial fold area. Thread should be protected from nostril and oral mucosa using a cannula (Fig. 8)



    Fig. 8. Protection of thread contamination using plastic cannula (from a needle cap)

    All soft tissue included in the suture is pulled in temporal direction (fixed to superficial extension of temporalis fascia and/or to zygomatic periosteum) by a medium tension of the suture. Skin and tissue impressions at perforation points should be very good managed by skin pull.

      

    Fig. 9. Combined traction on smas zygomatic extension and fat pad fascias using 3 perforation points with mucosal 2nd B. and 3rd C. perforation points; A. Puncture drawing, B. Before, C. After simultaneous medial SMAS lift and beautification rhinoplasty.


    TYPE III. TRACTION ON THE FAT PAD INCL. IT FASCIAS. WITH OR WITHOUT CHEEK DIMPLE;

    Using 2 points. Without cheek dimple;

    A. In young patients

    1st point. At zygomatic arch, point A2, 1 cm below the lateral cantus of the eye;

    2nd point. At upper end point B or B1, 3 mm laterally from nasolabial fold,

    1st step:

  • Introducing needle at 1st point A2; biting zygomatic periosteum in 45 degree direction to upper nasolabial point B. or B1. (through fat pad) and pulling out first end of thread;

    2nd step:
  • Through same points but medium deep through fat pad and pulling out second end of thread.

    The knot is made under very soft tension. Skin and tissue impressions at the perforation points should be free from attachments.

    Suture lifts fat pad area in superior posterior direction and fixes it to zygoma periosteum, enhancing anterior cheek-bone volume in higher position, and flattening nasolabial and second folds.

      

    Fig. 10. Traction on the fat pad incl. it fascias. Using 2 points in young patient. A. Puncture drawing, B. Before, C. After simultaneous medial SMAS lift and chin augmentation by suture to obtain the “beauty triangle”.

    B. In elderly patients.

    Using 2 perforation points. Without cheek dimple;

    1. at zygomatic arch, point A2, 1 cm below lateral cantus of the eye,

    2. at medial or lower nasolabial fold point B1, point C, or point D.

    That suture lifts fat pad area in higher position attaching it to the zygomatic periosteum, enhancing the anterior cheek bone

    A. B. C. D.

    E. F. G. H. I.

    Fig 11. Type III. Traction on the fat pad incl. it fascias: using 2 perforation points: Steps.

    In Asians, such procedure can remarkable reduce lateral bulging of zygoma, soften facial oval and change appearance into Caucasian like (Fig. 12).

    A. B.

    Fig. 12. Type III. Traction on the fat pad incl. it fascias. Without dimple. Using 2 perforation points. A. Before, B. After. Changing Asian face into a Caucasian oval appearance.

    C. With cheek dimple

    A. B. C.

    Fig. 13. Traction on the fat pad incl. it fascias. With cheek dimple. Using 2 points in elderly patient Using 2 points; ; A. Puncture drawing, B. Before, C. After.

    TYPE IV. TRACTION ON CHEEK SMAS

    Using 2 points:

    1st step:

  • Starting from the temporal point A (lower medial angle of hairline) in 45 degrees direction (to chin), biting superficial temporal fascia at point A., or zygomatic bone periosteum at point A1, biting cheek SMAS below zygoma and going out through skin in desired distance that will be enough to straighten cheek SMAS (point D. or other point D1 in near area (Fig 14A); feeding needle and puling thread out through both points;

    2ng step:

  • Passing same way in 1-2mm distance parallel to first pass and pulling out second end of thread.
    Knot is made under slight-medium tension. Skin dimples are managed by contra lateral pull on skin.

    Such suture moves volume in higher position, flattens the nasolabial, second, and marionette folds and lifts angulus oris.

    A. B. C.

    Fig. 14. Traction on cheek SMAS Using 2 points in young patient; A. Puncture drawing, B. Before, C. After simultaneous medial SMAS lift, temporal SMAS lift, beautification rhinoplasty, chin enhancement by suture, and lip augmentation.

    TYPE V. TRACTION ON CHEEK SMAS AND FAT PAD INCL. IT FASCIAS

    Using 3 perforation points:

    1. biting superficial temporal fascia or zygomatic bone periosteum at temporal point A or at zygomatic arch point A1 or point A2,

    2. at cheek SMAS below zygoma at desired distance;

    3. at desired place of nasolabial fold, 3 mm laterally

    Knot is made under very soft tension of suture. Skin and tissue impressions at perforation points should be managed by skin pull.

    Suture lifts fat pad in superior and posterior direction to periosteum bite in zygomatic bone, enhancing anterior cheek bone volume in higher position, flattening nasolabial and marionette folds, and forming younger looking cheek bone.

    A. B.

    C. D.

    Fig. 15. Traction on cheek SMAS and fat pad incl. it fascias. Using 3 points in elderly patient. A. Puncture drawing; B. Intra op: Right side made; C. Before and D. after medial SMAS lift, lip augmentation and beautification rhinoplasty.

    TYPE VI. TRACTION ON CHEEK SMAS AND FAT PAD INCL. IT FASCIAS WITH CHEEK DIMPLE

    Using 3 perforation points:

    1. at temporal point A or at zygomatic arch, point A2, biting superficial temporal fascia or zygomatic bone periosteum.
    2. at upper point B, 3 mm laterally from nasolabial fold,
    3. at smile point.D.
    A. B.

    Fig. 16. Traction on fat pad incl. it fascias. With cheek dimple. Using 2 points in elderly patient. A. Before, B. immediately after operation

    VII. CHEEK DIMPLE only

    Using 2 perforation points:

    1. at the zygomatic arch, at desired place – points A2 or A1, mostly point A2;

    2. at smile point D.


    MATHERIAL AND RESULTS

    782 patients were operated during the period between March1996 and December 2004 to improve check-bone and solve problems of ageing face, some like nasolabial folds, second folds, marionette folds, emptiness in the area, skin wrinkling etc. In 72% patients had simultaneous treatment of other face or body areas. In face combinations were mostly with temporal, brow lift, lower SMAS-platysma lift, chin enhancement and beautification rhinoplasties.

    Patients follow up vary from 5 month to 8 years.

    Medial lift     

    excellent

    good

    satisfying

    Under expectations

    Total number operated

    Corrected

    Type I

    256

    2

       

    258

     

    Type II

    267

    27

    5

     

    299

     

    Type III

      49

    3

       

      52

    2

    Type IV

      62

    7

       

      69

     

    Type V

      74

    12

       

      86

     

    Type VI

        4

     

    1

     

        5

    1

    Type VII

      12

    1

       

      13

     


    Results are mostly satisfactory to excellent. (Table 1). Patient’s satisfaction is mostly connected to lack of pain, short operation time, local anesthesia, immediate or short time recovery and fast return to social activities or work. Aesthetic coincidence with preoperative patient expectations in nearly full, sometimes a bit more expressive in the first days.

    In the first 7-10 days a sensation of hardening of operated area appears that is normal. Most patients love that sensation and describes it as desired.


    COMPLICATIONS

    In 1 patient after cheek bone lifting with dimples Type III, the dimple nearly disappeared 3 days after operation due to pillow pressure and the smiling effect of that side was lost. Immediate reoperation restructured the symmetry and the dimple successfully.

    In 2 patients on day one after operation, an additional pull on the skin was performed to obtain lifting level symmetry both sides. Correction was done under local anesthesia

    In the first 3-4 days five patients were complaining on feeling of overcorrection or too high lifting and projection of the cheek-bones. This is the period of most expressed swelling. These complain disappeared in 5 to 10 days.

    There was no other case of secondary correction after medial lift except the one reported for dimple stabilization.


    DISCUSSION

    Patient satisfaction is closely connected to individual possibility to correct proportions, volume and angle of check bone. So far there are not many methods of cheek-bone lift itself15-28. Classic rhytidectomies do not correct cheek-bone volume and position, do not change proportions even modern endoscopic methods33. Additional sutures and pull on the SMAS during rhytidectomy improve lower face and jowl. This effect we obtain in all types of our medial face lifts. Dimple surgery and methods are also rare. Pull in classic rhytidectomies is mostly posteriorly, but in our suture methods traction is mostly in cephalic or temporal direction. Skins pull in classic subdermal and deep rhytidectomies does not improve very much nasolabial and marionette folds that is the desired effect not only in elderly, but in young patients as well. Flattening of nasolabial fold demonstrates priority of our method compared to all other lifting methods. Complication rate rises with the extension of surgery.


    CONCLUSION

    Medial lift using Serdev suture methods is ambulatory, very well tolerated by patients, with immediate effect, with extremely short post operative period, fast recovery and nearly immediate return to social life. Complications are under 0,004% and patient’s satisfaction is extremely high, especially aesthetic one.

    Positive in our suture lifts is the possibility to correct desired area and improve neighborhood areas.


    REFFERENCES:

    1. Mittelman H, Newman J. Smasectomy and imbrication in face lift surgery.Facial Plast Surg 2000 May; 2: 173-82.
    2. Serdev, N. P. Forehead Subperiosteal Masklift in Combination with McIndoe Facelift Technique and Profile Correction. The 7th IPRAS Congress European Section, Berlin, Germany, June 2-5, 1993.
    3. Serdev N. P. Temporal SMAS lift without skin excision In: Lip Augmentation During Mask and SMAS Lift Procedure, AAARS Annual Meeting, New Orleans, USA, October 5-9, 1994
    4. Serdev, N.P. Temporal SMAS Lifting of the Face. Life Surgery Workshop. Unidad Medica Clinica Del Country, Bogota D.C., Colombia, November 8-10, 1999
    5. Serdev, N. P. SMAS Lifting of the Face by Minimal Incisions – the Serdev Technique. Life Surgery Workshop sponsored by International Academy of Cosmetic surgery and the Balkan Academy of Cosmetic Surgery, held at the Krilig Clinic in Caracas, Venezuela, November 12-18, 1999.
    6. Serdev, N. P. Principles of Face Beautification, Ier Congresso Internacional de Cirurgia Cosmetica, Buenos Ares Argentina, 31 Octubre – 1 de Noviembre 1999
    7. Serdev, N.P. Temporal SMAS lift, Lecture and Life Demonstration, 1st World Congress of Cosmetic Surgery with Life Demonstrations, Edsa Shangri-La Manila and Quezon City Medical Center, February 25-27, 2000. http://www.mpint.co.jp/apacs/Congress2000/con007.htm
    8. Serdev, N.P. Temporal SMAS Lifting of the Face, Combined with Liposuction and Chin Augmentation Using Suture. Life Surgery Workshop, Tel Aviv, Israel, April 20-24, 2000.
    9. Serdev, N. P. Principles of face beautification, The 3-rd World Congress of ISAS, Tokyo, April 8-10, 2000 , 9W58
    10. Serdev, N.P. Lifting del SMAS con Una Pequenna Incision Temporal, VIIIas Journadas Mediterraneas de Confrontaciones Terapeuticasen Medicina y Cirurgia Cosmetica, Sitges, Barcelona, March 16-19, 2000
    11. Serdev, N.P. Facial Rejuvenation by Minimal Skin Incisions, International Congress “Refinements in Aesthetic Surgery” Oradea, Romania, June 22-24,2000
    12. Serdev, N.P. AMBULATORY TEMPORAL SMAS LIFT BY MINIMAL HIDDEN INCISIONS, Int J. Cosm. Surg.2001;Vol. 1 No 2, Pages: 20 - 27 Nikolay P. Serdev, MD, PhD
    13. De la Fuente A, Santamaria AB Endoscopic subcutaneous and SMAS facelift without preauricular scars.Aesthetic Plast Surg1999 Mar-Apr; 23: 119-24.
    14. Maloney BP, Schiebelhoffer J. Minimal-incision endoscopic face-lift. Arch Facial Plast Surg 2000 Oct-Dec; 4: 274-8.
    15. Hagerty RC, Scioscia PJThe medial SMAS lift with aggressive temporal skin takeout. Plast Reconstr Surg 1998 May; 101 (6):1650-6
    16. Mitz, V, Peyronie M. The superficial musculoaponeurotic system (SMAS) in the parotid and cheek area. Plast. Reconstr. Surg. 1976; 58: 80.
    17. Cardoso de Castro, C. The role of the superficial musculoaponeurotic system in face lift. Ann. Plast. Surg. 1986; 16: 276.
    18. Kamer FM, Frankel SMAS rhytidectomy versus deep plane rhytidectomy: an objective comparison.ASPlast Reconstr Surg 1998 Sep; 102 (3): 878-81.
    19. Hamra ST. The tri-plane face lift dissection. Ann Plast Surg 1984 Mar; 12 (3): 268-74.
    20. Hamra ST. The deep-plane rhytidectomy. Plast Reconstr Surg 1990 Jul; 86 (1):53-61.
    21. Hamra ST, Composite rhytidectomy.Plast Reconstr Surg, 1992 Jul; 90 (1): 1-13.26.
    22. Mitz V, Use of deep planes in surgery of rejuvenation of the face Chirurgie 1991; 117 (4): 278-86.
    23. Ramirez OM, Maillard GF, Musolas A. The extended Subperiosteal Face lift: A definitive Soft-tissue Remodeling for Facial Rejuvenation. Plast Reconstr Surg 1991; 88:227-36.
    24. Bonnefon A Deep "en bloc" facial lift" Ann Chir Plast Esthet 1992 Jan; 37 (1), 85-94
    25. Bonnefon A. Deep vertical lift and its development regarding the central facial area and lower two-thirds of the neck. Our technique, Ann Chir Plast Esthet, 1999 Dec: 609-16.
    26. Teimourian B, Delia S, Wahrman A, The multiplane face lift.Plast Reconstr Surg 1994 Jan 93; 1: 78-85.
    27. Stuzin, J. M., Baker, T. J., Gordon, H. L., and Baker, T. M. Extended SMAS dissection as an approach to midface rejuvenation. Clin. Plast. Surg. 1995; 22: 295.
    28. Quatela VC, Sabini P. Techniques in deep plane face lifting. Facial Plast Surg 2000 May; 2: 193-209.
    29. Bosse, J. P., and Papillon, J. Surgical Anatomy of the SMAS at the Malar Region. In Transactions of the 9th International Congress of Plastic and Reconstructive Surgery. New York: McGraw-Hill, 1987: 348.
    30.Miura Y, Moura PD, Ramasastry S, Hochberg J. Can we simplify the nomenclature of the fascial lyers of the temporo parietal region? OnLine J Plast Reconstr Surg, Nov 1997;1: 1.
    31. Stuzin JM, Wagstrom L, Kawamoto HK, Wolfe SA. Anatomy of the frontal branch of the facial nerve: The Significance of the Temporal Fat Pad. Plast Reconstr Surg 1989; 83: 265-71.
    32. Hochberg J, Kaufman H, Ardenghy M. Saving The Frontal Branch during a Low Fronto-orbital Approach. Aesth Plast Surg 1995; 19: 161-163.
    33. Barton, F. E., Jr. The SMAS and the nasolabial fold. Plast. Reconstr. Surg. 1992; 89: 1054.

    Address for contacts:

    Nikolay P. Serdev, MD, PhD
    President, Bulgarian Society of Aesthetic Surgery and Aesthetic Medicine


    Medical Center
    Aesthetic Surgery and Aesthetic Medicine


    11 20th April Str., 1606 Sofia, Bulgaria
    Phone: +359 888 00 3772

    Fax: +359 2 951 5668


    E-mail: nserdev@infocom.bg

    http://www.drserdev.com

    Send for publication: 26. 11. 2001

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