Anterior SMAS
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Fig. 8.14 Placement of anterior SMAS
plication sutures beneath the elevated
cheek flap. After five sutures are placed
and clamped, they are then tied with
square knots.
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Anterior SMAS Plication During a Traditional Cervicofacial Rhytidectomy
A simplified method of improving the nasolabial fold as well as infraorbital hollowing can be achieved with anterior SMAS placation in combination with a SC rhytidectomy. Utilizing a Webster-type face lift, the anterior SMAS directly above the nasolabial fold is pliceted at a 90-degree angle (to the nasolabial fold), by approximately 1.5 cm, to the SMAS over the masseter muscle. Sutures placed superficially through the SMAS are oriented parallel to the
buccal branches of the facial nerve. Five interrupted clear 4.0 nylon sutures are placed 0.5 cm apart (Fig. 8.1 4). This plication improves the ptotic nasomandibular prominence, a fatty linear bulge at the anterior border of the masseter muscle (Fig. 8.15).
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Fig. 8.15 ptotic fatty linear bulge (nasomandibular prominence) at the anterior border of the masseter muscle
beneath the elevated cheek flap
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Patient Selection
This technique is useful in patients who wish to correct prominent nasolabial folds and infraorbital hollowing. This is typically an early aging sign and may or may not be accompanied by prominent jowls and neck laxity (Fig. 8.16). Traditional cervicofacial rhytidectomy does not improve prominent nasolabial folds or infraorbital hollowing. Traditional rhytidectomy can even temporarily deepen the nasolabial folds (Fig. 8.17). Patients who have had this operation and are dissatisfied with their midface are good candidates for revisional surgery (Fig. 8.18).
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Fig. 8.16 Preoperative face lift candidate. She presents with unwanted jowls, hollowing beneath her eyes and asymmetrical nasolabial folds.
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Fig. 8.17 Postoperative appearance after a traditional cervicofacial rhytidectomy (without anterior SMAS plication). Results demonstrate improvement of the jowls but temporary worsening of the nasolabial folds and lack of significant improvement of the hollow beneath the eyes
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Fig. 8.18 Postoperative appearance after anterior SMAS plication. Results show correction of prominent nasolabial folds and infraorbital hollowing.
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Preoperative Markings
Incision lines are drawn in a standard Webster facelift pattern (Fig. 8. 19). Surgical landmarks are drawn with the patient in a sitting position. A line is drawn from the lateral canthal area to a point 0.5 cm lateral to the oral commissure to the mandible. This marks approximately the medial extent of the anticipated SC undermining and includes the caudal third of the labiomandibular fold and nasolabial fold. Plication markings are made from the ptotic
nasomandibular prominence at a go-degree angle to the nasolabial fold. Anticipated plication is approximately1- 2 cm. The anticipated SC dissection extends medially over the malar eminence to the preoperative markings as well as onto the neck.
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Fig. 8.19 Preoperative SMAS plication markings. Markings indicate where sutures will be placed under the dermis to connect the ptotic linear bulge at the anterior border of the masseter muscle to the SMAS over the masseter muscle
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Placement of Anterior SMAS Plication Sutures
Lidocaine 0.25% with I:400,000 epinephrine is infiltrated into the SC plane of the face and neck. Wide undermining and retraction with appropriate lighting is necessary to expose the ptotic nasomandibular prominence. A long needle holder and forceps facilitate plication (Fig. 8.20). Vertical plication should be avoided because it could cause ectropion.
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Fig. 8.20 8 in (20.3 em) 1x2 teeth tissue forceps and 8 in fenestrated jaw needle holders
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Skin Trimming and Closure
The skin and scalp flap are trimmed and closed with minimal tension. Care should be taken not to elevate the sideburn excessively. The anterior SMAS plication alone without much skin excision will generally correct mid-face aging.
Troubleshooting
Dimpling of skin caused by sutures that connect the SC tissues and skin should he corrected with further undermining. The plicated anterior SMAS Can be palpated postoperatively but resolves after a few
months.
Complications
Robbins et al noted no complications including infections, nerve injuries or dehiscence in 226 patients over a 2-year period. One of the current authors (GJH) has not encountered complications although patients are informed of reported potential complications of rhytidectomy and placement of permanent sutures
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Further Reading:
Hamra ST 2002 A study of the long-term effect of malar fat
repositioning in face lift surgery: short-term success but long•term
failure. Plastic and Reconstructive Surgery 110:940.
Keller GS, Namazie A, Blackwell K. Rawnsley J, Khan S 2002
Elevation of the malar fat pad with a percutaneous technique.
Archives of Facial Plastic Plastic Surgery 4:20
Langdon RC 2005 Minimum incision face lift. In: Robinson JK,
Hanke CW, Siegel DM, Sengelmann RD (eds) Surgery of the
Skin. Else•.-ier, London, pagt'S 657-672
Langdon, RC, 2005. Advanced Face Lifting, Chapter 6
Orentreich DS, Orentreich N 1995 Subcutaneous incisionless
(subcision) surgery for the correction of depressed scars and
wrinkles. Dermatologic Surgery 21:543
OwsIey JQ, Zweifler M 2002 Midface lift of the malar fat pad:
technical advances. Plastic and Reconstructive Surgery 110:674
Pessa JE, Garza JR 1997 The malar septum: the anatomic basis of
Malar mounds and maIar edema. Aesthetic Surgery Journal 17:11
Robbins LB, Brothers DB, Marshall DM 1995 Anterior SMAS
plication for the treatment of prominent nasal mandibular folds
and restoration of normal cheek contours. Plastic and Reconstructive
Surgery 96:1279
Sasaki GH, Cohen AT 2002 Meloplication of the malar fat pads by
percutaneous cable-suture technique for midface rejuvenation:
outcome study (392 cases, 6 years' experience). Plastic and
Reconstructive Surgery 110:635
Webster RC, Smith RC, Smith KF 1983 Face lift: 3. Plication of the superficial muscolo-aponeurotic system. Head and Neck Surgery
6:696
Yousif NJ, Gosain A, Matloub HS, Sanger JR, Madiedo G, Larson DL 1994 The nasolabial fold: an anatomic and histologic reappraisal.
Plastic and Reconstructive Surgery 93:60
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