Are We Contributing to the Death of the SMAS?

Goals/Purpose: The facelift remains an incredibly popular plastic surgery procedure. The involvement of the superficial musculoaponeurotic system (SMAS) in facelift work first came into practice in the 1960s-1970s. Since its introduction, there has been notable evolution of SMAS techniques with increased knowledge in facial rejuvenation. With the evolution of technique and of trends in aesthetic preferences, there is continued reevaluation of the best, safest, and most effective ways to perform these procedures. Management of the SMAS is approached in a variety of different ways including plication, SMASectomy, high SMAS, deep plane, and extended SMAS and while long term results have been studied, the effects of these different means on the SMAS itself has not been thoroughly evaluated. In a small sample of patients who we performed a secondary facelift on, they were noted to have premature facial aging with loss of volume to necessitate the secondary facelift, often earlier than would be expected after a primary. On taking these patients to the operating room for a secondary facelift, they were found to have significant wasting or even nonexistence of the SMAS overlying the parotid gland with more normal, robust SMAS distally. This repeated finding garnered the question of what could be contributing to this complete loss of structure and volume. Could this be a matter of normal facial aging, global volume loss, any prior facial surgical intervention, or a specific procedure that was contributing. Consistently, these patients had previously undergone an extended SMAS facelift or extensive SMAS dissection in their prior surgeries.

Methods/Technique: A case review was performed of 13 patients noted to have SMAS compromise found during their secondary facelift procedure. When able to be identified, prior facelift techniques were documented. All secondary facelifts were performed by the primary surgeon. Primary facelifts were performed by a variety of other surgeons including the primary surgeon, most others of whom were known for extensive SMAS work.

Results/Complications: 13 patients who underwent secondary facelifts were found to have notable SMAS loss. In these patients it was found that their primary facelifts involved significant SMAS dissection.

Conclusion: While the extended SMAS technique and significant SMAS elevation can in some hands for some patients have incredible results, the long term effects of potentially compromising the SMAS integrity should certainly be considered. Though it is possible that these patients had rather punitive SMAS flaps at their initial procedures that were further weakened by elevation, it is something to potentially be avoided. It is difficult to determine whether these findings are more likely due to inherent patient characteristics, technique, or other factors that resulted in subsequent failure of large segments of the SMAS in this population. The findings are, however, striking enough that it should encourage plastic surgeons to look at whether or not we are ultimately leading our patients to premature facial aging and loss of tissue volume. If so, this could call for a change of practice to more limited SMAS dissection and avoidance of the extended SMAS technique. Ultimately, further investigation needs to be done on this finding to better elucidate potential causes and avoid future issue at the detriment of our patients.