Overview of SMAS Plication Facelift
Facial rejuvenation, or procedures that aim to make the face look younger, have become increasingly popular and complex over time. Since the early 1900’s, the demand for these procedures has been on the rise. In fact, since 2016, facelifts (known medically as “rhytidectomy”) have been among the top 5 most common cosmetic surgeries in the U.S., together with breast enlargements, eyelid surgery, liposuction, and nose reshaping.
People often seek facelifts because as they age, their skin loses collagen, making it less firm. Regular exposure to sunlight can also reduce skin elasticity. As people reach their 30’s and 40’s, they start to see a drop in the smoothness and fullness of their face. In the 60’s and 70’s, the natural cushioning fat in the face and the shape of facial bones begins to change. These changes are why most people who choose to undergo elective facelift procedures are women between their 30’s and late 70’s.
Facelifts can help people seeking improvement in the smoothness of their skin and contour of their jaw, and those dealing with paralysis on one side of their face. A less invasive form of facelift, called a ‘superficial musculoaponeurotic system (SMAS) plication’ facelift, is ideal for people with lean bodies who have a little sagging skin and jowls, but no major drooping of the cheek fat pads or deep facial lines. People with thick skin and more weight may not see as great a result from these less invasive facelifts.
The ‘SMAS plication’ facelift technique works to enhance the facial appearance by sharpening the angle of the jaw, reducing jowls, and improving the definition of the jawline. This technique was developed to provide a more effective way of lifting the soft tissues of the face, instead of just tightening the skin. It was first introduced by a Swedish plastic surgeon named Tord Skoog in the 1970s and has since gained popularity.
There are several ways to perform a ‘SMAS plication’ facelift, such as moving or tightening the layers of tissue. Despite the surgical risks, the chances of complications occurring during ‘SMAS’ facelifts are relatively low and patient satisfaction is generally high.
Anatomy and Physiology of SMAS Plication Facelift
The face is layered with different tissues, and understanding these layers is vital for surgeons to perform successful operations with minimal complications. One significant layer is the SMAS layer, which lies beneath fatty tissue and a layer of blood vessels that supply the skin.
The SMAS layer is placed right above a tissue layer called the parotidomasseteric fascia. It connects with several muscles around the face and merges with another muscle, called platysma, above the jawbone. This same layer sticks to the arch of the cheekbone but also connects to another fascia (or layer) named the temporoparietal fascia (TPF). The TPF then sticks to the bone of the head above the muscle on the side of the head, becoming the frontalis muscle and a layer called the galea aponeurotica. It’s essential to remember that this plane is a single structure to identify the location of the facial nerve branches, which are usually found beneath this layer.
The facial nerve, located deep within the SMAS layer, travels through a gland in the face called the parotid gland. This nerve then remains under the SMAS layer, running along the layer of the masseter muscle – a muscle you use to chew. During aggressive facelifting techniques, surgeons might find the facial nerve here. The branches of this nerve provide power to the facial muscles from their underneath surfaces, with a few exceptions for muscles deeper within the face.
The facial nerve is generally seen as having five main branches that separate from the main nerve trunk at a point within the parotid gland. The highest branch runs deep to the TPF and heads towards two muscles in the forehead and brow. Another lower division runs deep to the platysma muscle and powers several muscles around the mouth and neck.
Other branches of the facial nerve provide power to the middle face muscles and work in conjunction with a duct and blood vessels in the face. One branch controls eyelid closure, and another controls most of the midface muscles. This branch also helps to control your smile.
A nerve and vein that can be injured during facelift surgery lies beneath the platysma and above a muscle in the neck. The lower branch of the facial nerve often wraps around a facial vein which sits just behind the facial artery. This nerve is usually found above the lower edge of the jawbone, but there is evidence that injury to the neck branch nerve often leads to imbalance in the lower lip after surgery.
Furthermore, it helps to understand how the soft tissues attach to the underlying bone as it influences facial aging and therefore, surgeries to correct aging in the face. Ligaments along the jawbone are important in facelift surgeries, and cutting them during surgery can help shape the jaw, reducing jowls. Likewise, the skin’s attachment to muscle with minimal fat leads to the formation of folds around the nose and mouth, which get more pronounced with age. A procedure called a midface lift can lift these pads, giving a more youthful look.
Why do People Need SMAS Plication Facelift
A facelift using SMAS plication might be suggested by your doctor if you have any of the following conditions:
- Laxity in the skin or soft tissues of your lower face: this means that the skin and tissues of your lower face have become loose or saggy.
- Jowling: this refers to sagging skin below your jawline, which can make it look like you have a double chin or excess neck skin.
- Facial asymmetry due to chronic flaccid facial paralysis: this could be something you were born with, or it might be the result of a stroke, Bell’s palsy, or some other condition that has caused one side of your face to droop.
- Plastysmal banding: this is when you have visible, vertical bands of muscle in your neck. Your doctor might suggest a facelift with SMAS plication if you’re also planning to have a neck lift or a surgery called platysmaplasty, which tightens the muscles in your neck.
- Reasonable expectations for outcomes: Getting a facelift is a big decision. Your doctor won’t suggest this surgery unless they think you have a clear understanding of what it can and can’t do, as well as the risks and benefits.
Remember, everyone is different, so what works for one person might not work for another. It’s important to discuss your situation and options with your doctor in order to make the best decision for you.
When a Person Should Avoid SMAS Plication Facelift
There are several reasons why a person might not be able to have a SMAS plication facelift, a type of surgery that tightens the skin on the face:
If they are unable to set realistic expectations for the results of the surgery, it might not be suitable for them. The same is true if they have psychiatric conditions that might impact their recovery or perspective on the surgery.
It might not be possible to perform the surgery if a person has significant sagging (also known as ptosis) in the cheek fat, with deep lines running from the nose to the mouth (nasolabial folds). Likewise, if a person has a lot of fat in the facial tissues, the surgeon might not be able to perform the facelift.
Additionally, if a person’s weight tends to fluctuate or if they smoke, these factors could affect the success of the surgery and the healing process afterwards.
If a person has diseases that affect the body’s connective tissues (collagen vascular diseases) or other conditions that affect healing, the facelift might not be suitable. The same is true for those with uncontrolled diabetes, an underactive thyroid that isn’t being properly treated (hypothyroidism), or high blood pressure that isn’t well-managed.
Some people have conditions that affect bleeding, or they might need to take blood thinners around the time of the operation. If a person can’t safely stop taking these medications, surgery might be too risky.
Malnutrition can also hinder proper healing, rendering the facelift unsuitable. Those with poor heart and lung health may not be able to endure the stress of surgery.
Equipment used for SMAS Plication Facelift
To perform a type of facelift called SMAS plication, the doctor uses several tools, including:
– Different types of scissors like Gorney-Freeman, Kaye, Goldman-Fox, Castañares or something similar for the facelift. Mayo, iris, or tenotomy scissors are used specifically for suturing, which means sewing up the skin after the procedure
– Retractors such as Freeman rake, Joseph double prong skin hooks, Ferreira facelift retractor, these tools help to gently hold back the skin and tissues, so the doctor can clearly see the area he’s working on
– Various types of forceps like Adson-Brown and 0.5 mm Castroviejo, which are used for holding and maneuvering tissues during the procedure
– Needle drivers, like Halsey or Webster and Castroviejo, which are used to grip the needle while suturing so that the surgeon can have better control
– A scalpel with several #15 blades and a #3 Bard-Parker handle, which is used to make precise cuts
– Electrocautery tools: this includes both bipolar and monopolar, which are used to stop bleeding by sealing off blood vessels
– Various types of sutures, these are the threads used to sew up the surgical incisions. Types include 2-0 quill suture, braided polyester or polydioxanone, 4-0 polyglactin, 5-0 nylon, and polypropylene
– A skin stapler, used to quickly and efficiently close wounds
– A skin marker for mapping out the surgery area
– Hypodermic needle and syringe which are used for injecting local anesthetic or a solution that makes tissues swell (tumescent solution), which can ease the procedure and minimize blood loss
– Dressing supplies for covering and protecting the treated area after the procedure is complete.
Who is needed to perform SMAS Plication Facelift?
To do a facelift, which is technically called a SMAS plication, a team of medical professionals is required. This list includes the following people:
A surgeon who leads the entire procedure. Surgeons are highly-skilled doctors who conduct the operations.
A first assistant who might be needed to support the surgeon during the operation.
A scrub tech. They are the ones who ensure everything is clean and ready for the operation. They also assist the surgeon during the procedure.
A circulating nurse. They move around the operating room to supervise and assist with the operation. They ensure everything goes smoothly and safely.
An anesthesia provider. They might be needed depending on the situation. This person is responsible for numbing the area to be operated on or making you sleep during the operation to make sure you don’t feel any pain.
Preparing for SMAS Plication Facelift
During surgery, a patient lies flat on the operating table. The doctors may use general anesthesia or a lighter version known as sedation to make the patient sleep and not feel any pain. If full anesthesia is used, a tube could be placed either through the mouth or the nose to help the patient breathe easily. This tube is secured with a strong thread to ensure it stays in place throughout the surgery. This is important, especially when the surgeon is working around the neck and mouth area.
Before the actual procedure begins, the surgeon numbs the area with a medicine to reduce pain or a special solution that causes temporary swelling to make the area easier to work on. After that, the area is then cleaned using a special anti-bacterial solution. This helps to kill any germs around the surgery area and prevent infections. If the surgeon is also planning to do an eye surgery (blepharoplasty), they will use a milder cleaning solution around the eyes to avoid hurting them, and the eyes might be covered to protect them.
How is SMAS Plication Facelift performed
The surgical process begins with administering a special type of local anesthetic called a tumescent solution. This is a diluted solution of an anesthetic (like lidocaine), mixed with saline (a salt-water solution), sodium bicarbonate, and epinephrine to reduce bleeding. This is injected into the area underneath the skin that is going to be operated on. This solution makes the area firm and easy to work on.
The surgeon then makes a cut starting in the area near your temples and going towards the ear. For women, this cut might be slightly hidden near the inner edge of the ear flap to minimize visibility. Depending on the patient’s need, this cut can be made longer.
The next step involves separating and lifting the skin flap with scissors from the underlying tissue, a technique also known as flap elevation. The surgeon then identifies a strategic layer of the face called the Superficial Musculo-Aponeurotic System (SMAS), which is a layer of tissue that supports the skin and is located just beneath the surface fat layer.
The surgeon will move the SMAS layer to achieve the desired lift and removes any extra tissue in the area falling behind the ear. Once the surgeon is satisfied with the new position of the SMAS layer, sutures (stitches) are used to keep it in place. The surgeon then carefully stops any bleeding and makes sure the skin is placed correctly and isn’t stretched too much.
The cut is closed with stitches and/or staples and the patient is advised to sleep with their head elevated for the first week after surgery to lessen swelling. A special neck support dressing is also provided for one to two weeks post-operation. Tests are removed on the 7th day, post-surgery, and patients are expected to return for follow up visits on the 3rd and 6th weeks post-surgery.
Depending on the patient’s situation, a modified version of this surgery can be performed. This requires only a short incision just in front of the ear and allows for a simpler, less invasive procedure. This technique is also beneficial because it not only addresses sagging skin on the lower face but also lifts the middle area of the face.
In some cases, patients may return for a redo of the procedure. Although previously operated skin is usually easier to work with, it can be more challenging if the operation is being performed by a different surgeon than the one who did the first surgery, due to differences in surgical approach and incision placement.
Possible Complications of SMAS Plication Facelift
After having their appendix removed (an appendectomy), some people might experience complications. One such common complication is an infection at the site of the surgery, like when the wound from the surgical procedure becomes infected. This can happen to up to 10% of people who get their appendix removed, particularly if their appendix burst before removal.
There are two kinds of wound infections that might occur: superficial and deep. Superficial infections occur within 30 days after the surgery and affect the skin and the soft tissue just beneath the skin. Doctors often diagnose superficial infections by looking for signs of pain, swelling, and redness near the surgical cut. If the wound is oozing pus, or if the culture test from the wound comes back positive, it further supports the diagnosis of a superficial infection.
Deep wound infections, on the other hand, appear between 30 to 90 days after the appendectomy and affect the muscles and other tissues beneath the skin. If you’re experiencing pain near the surgical cut, show tenderness, and running a fever, it might be an indication of deep wound infection. The diagnosis is further supported if the incision site is leaking pus or if the wound reopens.
To prevent post-surgery wound infections, doctors often prescribes antibiotics before the surgery, meticulously cleans the wound during the surgery, and uses specialized retractors and rinses the surgical area with a sterile solution.
Comparatively, a laparoscopic appendectomy, a less invasive surgical procedure to remove the appendix, is associated with a decreased risk of a surgical cut infection but might increase the risk of internal infections in the abdomen and pelvis.
About 9.4% of people who undergo an appendectomy due to complicated appendicitis might develop a pelvic abscess filled with pus after the surgery. Several procedures are recommended to reduce this risk, including rinsing the area within the abdomen during the surgery. However, different procedures may result in different outcomes, and no one method has been proven to be most effective.
A rarer issue is stump appendicitis, where not all the appendix tissue is removed during the operation, and the leftover tissue causes a reoccurrence of appendicitis. This usually happens when the appendix has burst. The recommended procedure is to save less than 5 millimeters of the appendix to minimize the risk of this complication.
The risk of death associated with having an appendectomy is quite low and is generally considered a safe surgical procedure. However, the mortality rate can vary depending on the country, with more developed countries having a lower rate (0.09% to 0.24%), and developing countries having a higher rate (1% to 4%).
What Else Should I Know About SMAS Plication Facelift?
If your appendix, a small pouch-like structure connecting to your large intestine, becomes inflamed, it’s called appendicitis. Appendicitis needs prompt attention because the risk of the appendix bursting or perforating is between 16% and 36% within 36 hours and increases by 5% every 12 hours. This is why early diagnosis and removal of the appendix (appendectomy) is crucial.
If your appendix is removed without it having burst (nonperforated appendicitis), you’ll have to stick to a diet of clear liquids at first, slowly getting back to a regular diet. You may not need antibiotics, and you can likely leave the hospital 1 to 2 days after the surgery. In some instances, you might even go home on the same day of the surgery, especially if a keyhole (laparoscopic) approach is used.
If you’ve had a more challenging case of appendicitis where your appendix burst (complicated appendicitis), your hospital stay will be longer – typically around 5 to 7 days. In these cases, it’s important that you can eat properly again to avoid a condition called ileus (when food doesn’t pass through your intestines as it should). You’ll also likely need antibiotics for 3 to 5 days.
There are two main types of surgery used to remove the appendix: an open approach and a laparoscopic approach. In general, the laparoscopic approach is preferred. This is because it often results in fewer wound infections and shorter hospital stays. However, in some cases, it might be necessary to switch from a laparoscopic to an open approach, depending on various factors like the surgeon’s skills, the availability of specialized staff and equipment, and your overall health condition.
Occasionally, the appendix might look normal during surgery, but it might still be removed if you’ve had symptoms of appendicitis as it could still be diseased. Also, in certain conditions, the appendix could be used as part of a medical procedure to improve bowel function.
Laparoscopic surgery is preferred for certain groups of patients, such as those over 65 years of age, children, and pregnant women, because it has fewer risks. So, if you think you might have appendicitis, it’s important to get it checked out straight away.