Overview of Extended SMAS Facelift
A facelift, also known as a rhytidectomy, was the third most common cosmetic surgery performed in the United States in 2020. It falls just behind nose reshaping surgery (rhinoplasty) and eyelid surgery (blepharoplasty). As we grow old, our skin and the soft tissues in our face can start to sag and lose fat, which can cause wrinkles and changes in facial shape such as hollow under-eye areas, visible cheek wrinkles, lowered cheek fat, sagging jowls, deep smile lines, and the appearance of lines around the mouth. A facelift aims to lift and reposition these saggy tissues to restore the volume, shape, and youthfulness of the face.
Over time, the process of facelifts has gotten more advanced. It has moved from simple skin-cutting along natural lines to more advanced methods. One such method is the minimal access cranial suspension or lifting of the face using small incisions. Another method involves manipulating a layer of the face called the superficial musculoaponeurotic system (SMAS). There are lots of ways to do a facelift, and the method chosen usually depends on what the patient needs and what the plastic surgeon specializes in.
The face and neck have five main layers of soft tissue, in order from outermost to innermost: skin, the layer of fat under the skin, the superficial fascia (another name for the SMAS when it’s in certain parts of the face), loose tissue that connects muscles, and the deep fascia which is a layer of fibrous tissue. An advanced type of facelift called the extended SMAS technique works on the SMAS to lift and reposition it. The reason for the name “extended” is that this method works on the SMAS more comprehensively and further down the face than other methods. This technique also uniquely rejuvenates the middle part of the face. This is done by moving sunken tissue upwards to enhance facial volume and cheek augmentation, thereby restoring a youthful appearance.
Anatomy and Physiology of Extended SMAS Facelift
The head and neck area consists of five critical layers that are known to surgeons. From the outside to the inside, these are the skin, the fatty layer just beneath the skin, the superficial tissue layer, the thin, loose areolar tissue layer, and the deep layer of fascia (a band or sheet of connective tissue). In the middle of the face, the superficial layer is commonly known as the superficial musculoaponeurotic system (SMAS).
The names of the third layer changes based on the area; it is the frontalis muscle on the forehead, the temporoparietal fascia on the sides of the head, the SMAS in the middle of the face, and the platysma in the neck. The deep layers also have different names according to their positions in the face and neck. These include the deep temporal fascia or temporalis muscle fascia, the parotidomasseteric fascia (around the jaw), the periosteum under the scalp, and the deep cervical investing fascia in the neck.
The SMAS varies in thickness depending on the region of the face, being thicker on the sides and thinner in the middle. It is usually tightly attached to the skin and loosely attached to the fifth layer. This allows for careful scraping away (blunt dissection) below the SMAS. There are fibrous links, or retaining ligaments, that provide support and stability to the surrounding layers. These ligaments need to be surgically cut in a facelift operation to permit the repositioning of skin and soft tissues, and then they are repaired with stitches.
The area on the face located above the mandibular ligament (a ligament near the jawbone) and below the zygomatic ligament (a ligament near the cheekbone) is called the modiolar peninsula. This area is typically not touched during a specific kind of facelift procedure known as the extended SMAS technique. Occasionally, it provides an anchor point for stitches.
The fatty tissue in the middle of the face is called “malar fat.” This fat gives the face volume and a youthful look. One advantage of the extended SMAS technique is restoring this facial volume.
The branches of the facial nerve (a nerve supplying muscles of the face for movement) take different paths after passing through the parotid gland (a major salivary gland). These branches tend to stay just above the masseteric fascia (a thin covering layer above the muscle on the side of the jaw). They generally travel along the deep surfaces of the facial muscles to provide nerve supply. The mentalis, levator anguli oris, and buccinator muscles, which are deeper in the face, receive their nerve supply from their superficial surfaces. Doctors must be aware of this arrangement to avoid nerve damage during surgical procedures. One nerve that is more often injured than the facial nerve’s branches is the great auricular nerve, which starts from the back part of the side neck muscle (sternocleidomastoid muscle) and moves upward, roughly halfway between the mastoid (a small protrusion from the skull behind the ear) and the angle of the jaw, just behind the external jugular vein.
Why do People Need Extended SMAS Facelift
If you’re noticing some signs of aging in your face and are interested in looking younger, you might be a good candidate for a type of surgery called an extended SMAS facelift. This surgery is especially beneficial for people who’ve lost fullness in their cheeks, also known as malar volume.
Before deciding to have this surgery, it’s important to think about why you want it and to have a realistic idea of what it can do for you. Remember, while this surgery can enhance your appearance, it won’t make you look perfect. This is why it’s crucial to fully understand the risks involved and have a clear expectation about the results.
When a Person Should Avoid Extended SMAS Facelift
The extended SMAS technique, a type of facelift, may not be suitable for everyone. Some conditions might not make it a good fit. For instance, if you smoke, have a tendency to form thick or abnormal scars (keloids), are on blood thinners, or have had a certain type of deep facelift surgery in the past (rhytidectomy), this procedure might not be for you. It’s also not fit for those with unrealistic expectations about the results. Since there are different types of facelift techniques, this might not be the best one for younger patients or those who still have a youthful appearance in the middle part of their face.
It’s crucial for your doctor to know about any mental health conditions you might have, any other medical issues, and your current life situation. All of these can affect the outcome and the safety of this surgery. Patients with certain mental health conditions, such as narcissistic personality disorder, body dysmorphic disorder, and others, should first undergo a mental health checkup and treatment if required before considering this or any cosmetic procedures.
Noteworthy is that facelift surgeries have been associated with a high rate of depression after the operation. Therefore, if you have a past history of depression, you should have an in-depth conversation with your doctor about this risk before the procedure. The surgery might need to be delayed if it’s determined that you might benefit from starting on medication beforehand.
Equipment used for Extended SMAS Facelift
In different hospitals and settings, the exact tools used for a facelift procedure, also known as an extended SMAS rhytidectomy, can vary. However, typically a facelift involves using certain specific tools. These include two different kinds of scalpels (#10 and #15 blades), a special retractor and light source designed for facelifts, facelift scissors, tools called Trepsat dissectors, devices to drive the needle through the skin (needle drivers), forceps, a tool to stop bleeding (electrocautery), suction, and different kinds of stitches (sutures) to close the wound and hold the tissues in place.
Specifically, strong 2-0 polyglactin sutures are used to secure the layer of tissue under the skin (SMAS flap) in its new position. A thinner kind of suture, 5-0 polypropylene, is used to close the skin in front of the ear. And for closing the rest of the incision, finer absorbable sutures are used, typically 4-0 to 6-0 plain gut sutures, which the body gradually dissolves on its own over time.
When the procedure is finished, a thick, compressive bandage is usually applied to the area to reduce swelling and support the new shape of the face.
Who is needed to perform Extended SMAS Facelift?
A facelift is a complex procedure, often combined with other cosmetic surgeries like eyelid surgery, fat removal, skin smoothing, or forehead lift. Because of this, it’s preferred that patients are put into a deep sleep during the surgery, making it easier and safer. In addition to the person who gives the sleep medication (the anesthesia provider), a nurse and a surgical technician are needed. Someone to assist the surgeon is also very helpful.
After the surgery, nurses who focus on helping patients recover at home are super important. They do tasks like caring for the surgical area, removing stitches, and providing additional support for the patient. Without them, the surgery’s results may not be as good as they could be. This is why every member of the medical team plays a key role in your health and recovery.
Preparing for Extended SMAS Facelift
Before a facelift surgery, you should stop smoking for at least 3 to 4 weeks as it improves your body’s ability to heal. Additionally, try to stop any blood thinners, if you can, before the procedure to reduce bleeding during and after the surgery. In a pre-operation visit, your plastic surgeon will examine your face to notice any imbalances and check the functioning of some of the nerves in your face. This helps them plan the surgery more accurately. They will also have you sit upright so they can better understand how your soft tissue has changed with age, helping them plan the surgery more efficiently.
Just before your procedure, your surgeon will use a marker to outline where they intend to make cuts and lift the skin. They may choose to mark some areas like main ligaments, muscles, and the path of certain nerves. This is done to avoid unwanted damage while performing the surgery.
How is Extended SMAS Facelift performed
The extended Superficial Musculo-Aponeurotic System (SMAS) technique is a surgical process to help reduce facial aging signs. During this procedure, you would be deeply sedated or put to sleep. You’ll be lying flat on your back and the surgical table may be moved around to give the surgeon the best position to work on your face. Your face will be cleaned and prepared in a sterile manner to avoid infection.
To start, the surgeon will inject a traditional numbing solution called a tumescent solution along the planned cut lines. This helps to numb the area and reduce bleeding. Also, a mixture of two drugs, bupivacaine and lidocaine, would be injected into the planned surgery sites to help separate tissue layers and prevent bleeding.
The surgeon makes an angled cut with a scalpel at your temple. This is designed this way to preserve hair follicles. Then the cut goes down behind the ear and then along the hairline at the back of your head. For male patients, a slightly different cut is made to avoid moving hair-bearing skin to the front of the ear.
After the cut, a skin flap is lifted towards your cheek, from the mastoid towards the neck. This is done while taking care not to damage any important nerves such as the great auricular nerve. The surgeon will then make a cut into the SMAS layer, and perform careful dissection.
This procedure also involves working around the muscles of your face, taking particular care to avoid damaging nerves that control facial movements. For example, the surgeon dissects around your cheek and jaw muscles, making sure to avoid the inferior border of the cheekbone where a branch of the facial nerve runs.
At times, there might be some bleeding from small vessels in the course of the surgery. This can be stopped using a device that delivers a focused electric current to coagulate the blood. And occasionally, the surgeon might need to make another cut beneath the chin to help with the work on your factor tissues. Throughout the procedure, a surgical assistant will be checking for unwanted muscle movements that might signal nerve injury.
When the dissection is completed, the loose SMAS layer is pulled and anchored at your ear and the back of your head using strong sutures. Excess skin is cut away. Occasionally, some extra dissection might be needed to smooth out any wrinkling. The skin is then sewn up using stitches that will dissolve over time. Applying an antibiotic to the cuts helps prevent infection. Finally, a compression dressing is applied to reduce swelling and bleeding.
Possible Complications of Extended SMAS Facelift
Complications or problems that can happen after an extended SMAS facelift, a type of facelift surgery, are similar to those faced after other types of facelifts. These include bruising (hematomas), fluid buildup (seromas), swelling (edema), damage to the great auricular nerve or facial nerve branches, temporary nerve damage (neurapraxia), not-so-good looking scars, changes in hairlines, ear abnormalities such as the “pixie ear deformity” or changes to the tragus (part of the ear), wound infections, and blood clots in deep veins (deep vein thrombosis or DVT).
Bruising, or hematomas, are especially concerning because they can lead to skin tissue dying (flap necrosis) and, in some cases, even problems with breathing. However, the most common problem after an extended SMAS facelift is that the patient is not happy with the results.
What Else Should I Know About Extended SMAS Facelift?
A facelift is a surgical procedure useful for improving signs of aging in the face and neck. However, the method used to do this isn’t one-size-fits-all; it needs to be adapted to meet each person’s unique requirements. One technique, known as the extended SMAS method, is particularly good for people who need to improve the look of both the middle and lower parts of their face and neck.
SMAS stands for superficial musculo-aponeurotic system, which involves the tissues beneath the skin of your face. This method is beneficial because these tissues are firm and allow for a more secure and long-lasting result, reducing the chance of the facelift effect disappearing over time.
During the surgery, the doctor lifts up the facial skin, tightens and secures the SMAS layer underneath. The lifted skin is then laid back down without any tension, while any extra skin is removed. This maintains the natural look and feel of your face.
By lifting and tightening the SMAS layer towards the top of your head, you’ll notice an increase in the fullness of your face, a more pronounced cheekbone area, and a smoother neckline. All these changes contribute to a more youthful look, which both patients and doctors are usually happy with.