Facelift with SMAS Flaps

It is not possible to design a ‘universal’ facelift technique. Each patient will present with a unique set of problems that requires precise anatomic diagnosis and an appropriately planned and individualized surgical repair. Attractive and natural-appearing rejuvenation of the face is not possible without diverting tension away from the skin to the superficial musculoaponeurotic system (SMAS) and platysma, and unless other deep layer structures and the aging midface is addressed.

Skin has a covering function rather than a structural or supporting one. Using skin as the vehicle to support sagging deep layer tissue corrupts its function and results in abnormal tension and related secondary problems including poor scarstragal retraction, ear lobe mal-position, and a tight and unnatural appearance. Using the SMAS to lift sagging facial tissues and restore facial contour circumvents the problems associated with skin-only facelifts .

Most midface lifts are conceptually flawed in that they erroneously assume the problem seen in the anterior upper cheek to be solely one of tissue sagging. Careful evaluation of most patients who need a midface lift will show that they also need a facelift and it is unusual to encounter a patient with significant midface aging who does not also have sagging in the cheek and jowl. Midface lifts as a

result are arguably more logically performed in conjunction with a formal facelift procedure rather than as isolated, standalone procedures. 


  1. Skin only,

The fundamental flaw in skin-only facelifts, mini-lifts, and similar procedures is that skin is meant to serve a covering function and not a structural or supporting one. There are some reasons why skin-only resection should not be relied on when surgically rejuvenating the face

Skin is intended to serve a covering function, not a structural or supporting one. Tightening skin corrupts its natural covering function and results in unnatural appearances and the older and more inelastic the skin. Examination of the faces of young persons shows their faces are not tight. Skin tension flattens contour, rather than restoring it and because skin stretches as tension is applied, objectionable temple, sideburn and occipital hairline displacement is difficult to avoid when skin-only facelift techniques are used. Skin is not capable of providing sustained support of ptotic deep layer tissue. There is conceptual and technical simplicity, although initial outcomes of skin-only procedures may appear good, as an elastic layer, skin will rapidly stretch and any improvement obtained will typically be quickly lost.

  1. SMAS (Superficial Musculoaponeurotic System)

Repositioning ptotic facial tissue using the SMAS is arguably the single most important advance in facelift technique since the inception of the procedure. Each has certain advantages and disadvantages, but all share advantages over traditional skin-only procedures as follows:

  1. Most changes in the aging face are the result of sagging of tissue deep to the skin, and not the skin itself – the SMAS is more closely associated with the tissues that sag as the face ages than skin, and it is therefore arguably a more logical layer to use to restore them to a more youthful position;
  2. SMAS, can be used to divert tension away from the skin, and this will avert most secondary facelift deformities;
  3. SMAS lifts provide a means by which facelifts can be repeated without producing excessive skin tightness.
  4. I commonly use SMAS for facelift in my practice.
  • SMAS plication,

SMAS plication is perhaps the simplest technique to modify the SMAS.

It is technically less demanding and time consuming, with wide skin flap undermining; contour irregularities if sutures are not placed carefully; potential injury to facial nerve branches and parotid gland or duct; little if any midface improvement.

  • SMASectomy,

Tension can be set low, and sideburn displacement and shifting of cervical wrinkles onto the face can be minimized,

Wide skin undermining; facial nerve branches at risk when SMAS excised and sutured; may be contour irregularities; minimal improvement in midface,

  1. Deep plane,

Advantages of the deep plane technique include, single layer dissection and therefore flap elevation is easier and less time consuming than multilayer dissections in which both a skin and SMAS flap are raised;  the flap is thicker and arguably has a better blood supply then when a layered dissection is made, and therefore may be safer in smokers or other patients with compromised circulation. Potential disadvantages are: Potential excessive sideburn displacement, unnatural appearances caused by extraordinary tension; midface improvement not always as expected; facial nerve branches and other structures at risk.

  1. Endoscopic,

Despite the importance of concealing scars in aesthetic surgery, other surgical specialties were the first to introduce and employ endoscopic techniques. The major obstacle to endoscopic facelift is that skin redundancy remains a signifi cant component of the aging deformity and although some support of deep layertissue can be obtained, the endoscopic technique does not provide a means for this to be excised.  For the most part the improvements obtained in endoscopic facelifts are limited largely to midface elevation,

  1. Midface,

The midface is generally defined as an inverted triangular area situated over the anterior upper cheek.

In healthy, youthful appearing men and women this area is full and makes a smooth transition to the adjacent cheek and lower eyelid. As one ages however, there is generally atrophy of, and loss of volüme from this area, and over time this results in an ill, haggard, and elderly appearance. The recognition of midface ptosis as a signifi cant component of the changes occurring in the aging face, combined with the realization that the traditional SMAS facelift produced little or no improvement

in the midface region, has led to a variety of procedures designed to specifically target the midface area. Many of these techniques are now being performed in conjunction with lower

eyelid surgery. There would be complications include lid retraction, ectropion, canthal displacement and dry eye problems.

  1. Mini-lift,

Mini-lift is used to describe the simple excision of skin in a younger patient, but is sometimes used to

refer to procedures of limited scope performed on older patients. Minilifts typically use short-scar incision plans and do not include modification of the SMAS and platysma.

Unlike skin-only facelifts and mini-lifts worsen skin tightness and problems associated with it. Minimal improvements are can be made to aging face.


  1. Aging and breakdown of the skin surface,
  2. Facial sagging, skin redundancy, and loss of youthful facial contour,
  3. Facial wasting, atrophy and age-related lipodystrophy

Proper treatment depends upon the degree to which each of these problems is present, the patient’s priorities, and the time, trouble and expense the patient is willing to endure to obtain the desired improvement.

Patients primarily concerned with surface aging of their face may not require surgery and may achieve the type of improvement they desire through surface treatments of the skin. These include:

  1. Skin peels,
  2. Ablative and non-ablative skin resurfacing,
  3. Chemodenervation (botulinum toxin type A injections),
  4. İnjection therapy
  5. Cutaneous laser and other treatments designed to remove or reduce age spots, spider veins, wrinkles and other age-related skin surface imperfections.

Patients primarily concerned with facial sagging, skin excess, and loss of facial contour will typically be disappointed if surface-only treatments are employed. They require formal surgical lifts in which sagging tissue is repositioned and redundant tissue is excised if these problem are to be properly corrected and an attractive and natural-appearing improvement obtained.

Patients with significant facial atrophy and age-related facialwasting achieve suboptimal improvement from both surface treat ments of facial skin and surgical lifts. Smoothing skin will not disguise a drawn, ill, or haggard appearance resulting from the loss of facial volume, and it is difficult to create natural and attractive contours by lifting and repositioning tissues that have abnormally thinned with age. These patients may require volume replacement, by autologous fat grafting or other means, in conjunction with their surgical procedure to achieve a satisfactory result.

Pan-facial rejuvenation,

Isolated aging rarely occurs in the lower face and neck, and many if not most patients requesting facelift surgery need forehead and eyelid procedures as well. Many are confused, however, by the term ‘facelift’ and take it to imply correction will be made in all areas. These patients must be counseled carefully because the facelift itself will produce little if any improvement in upper facial deformities and tends to unmask and draw attention to them.

It is also not uncommon for patients to request surgery on their neck only. Although such a plan is acceptable for some men, failure to concomitantly restore attractive cheek contour and lift sagging jowls in women generally results in an unnatural and unfeminine appearance.

In addition, if an aggressive platysmaplasty is performed as part of an isolated neck lift, sagging in the cheeks and jowl area can be accentuated as platysma tightening exerts a downward pull on tissue in these areas.

Preoperative Planning

  1. Temporal incision

Patients best suited for this incision plan are usually young and troubled by mild cheek laxity only. In many other situations however, larger skin shifts and the presence of sparse temple hair can result in unnatural and tell-tale displacement of the temporal hairline and sideburn if such a plan is used. Proper analysis, careful planning and the use of an incision along the hairline, when indicated, are needed.

Important factors in choosing incision placement;

  1. Distance between the lateral orbit and anterior aspect of the temporal hairline
  2. Estimate of the skin redundancy over the upper cheek;

Patient considerations;

Options for the placement of the temporal portion of the facelift incision should be discussed with any patient in whom significant dis- placement of the temporal hairline or elevation of the sideburn might occur. Incision placement is best presented as a choice between two imperfect alternatives and it is wise that the final decision about where the incision is located is made by the patient after appropriate discussion has been made. The patient should be informed that placing the incision in a tra- ditional location within the temporal scalp will help conceal the scar, but often at the expense of a large and objectionable displacement of the temporal hairline and sideburn, and compromised improvement over the temporal face. This inevitably results in an old and unnatural appearance and is usually immediately obvious, even upon a casual glance and at a distance.

An incision along the hairline will prevent hairline displacement, and although a scar will be present where the incision was made, it is usually inconspicuous and will not be noticed by others if wound closure is properly performed.

A suboptimally healed incision along the hairline can be concealed with makeup or tattooed or revised, but a significantly displaced hair- line is difficult to conceal and a challenge to correct. In my experience most patients are disturbed by the prospect of temple and sideburn hair displacement, and recognize this occurrence as a tell-tale sign that a facelift has been performed. When counseled properly and given the choice, many readily consent to incision placement along their hairline.

Assessment of temporal skin show. The distance between the lateral orbit and the temple hairline and how it changes with skin flap shift must be considered when planning the temporal portion of the facelift.

Plan for incision in the temporal scalp. This plan is used for patients predicted to have minimal shift of sideburn and temple hair after elevation of the cheek flap. It will not be appropriate for all patients. Plan for incision along the temporal hairline. An incision along the temporal hairline should be considered whenever objectionable displacement of the sideburn and temple hair is predicted.

  1. Preauricular incision

Open to scrutiny, the preauricular region exists as a frequent point of reference for those seeking

to identify a facelift patient.

Traditional incision vs retrotragal incision

Traditionally, incisions in the preauricular region are made well anterior to the anterior border of the helix and continued inferiorly, anterior to the tragus. Unfortunately, most patients have a marked gradient of  color, texture, and surface irregu- larities over the preauricular area and a tell-tale mismatch will be evident, even in the presence of an inconspicuous scar.

For these reasons, and in all but the unusual case, the preauricular portion of the facelift incision should be precisely placed along the posterior margin of the tragus, rather than in the pretragal sulcus.

In the male patient, the tragus can be kept free of beard hair by intraoperative destruction of beard follicles from the underside of the tragal flap

Traditional location of the preauricular incision. This plan places the preauricular scar in an area open to scrutiny and brands the patient as having had facelift surgery.

Marginal tragal (retrotragal) plan for the preauricular portion of the facelift incision. Placing the incision along the natural anatomic interfaces conceals the scar and disguises differences in skin color and texture on each side of it.

  1. Perilobular incision,

To obtain a natural perilobular appearance, it is essential to preserve the natural sulcus between the ear lobe and the cheek and to avoid excision of this aesthetically important anatomic subunit.

  1. Postauricular incision,

The postauricular portion of the facelift incision should be marked directly in the existing auriculomastoid groove and the mark turned posteriorly at the approximate level of the anterior crus of the anti- helix. Marking must be made with the ear resting near its natural anatomic position. If the ear is pulled too far forward while marks are made, mastoid skin will be pulled anteriorly over the posterior surface of the concha and the incision will end up posterior to its intended location. Incorrect marking in this manner is the most common cause of a poorly situated postauricular scar.

  1. Occipital incision,

Planning the location for the occipital portion of the facelift incision is conceptually similar to that of the temple region and the incision plan must address similar concerns of hairline displacement and scar visibility.

  1. Submental incision,

Most facelift patients require modification and repair of the neck and submental regions that can only be performed through a submental incision. The submental incision should be placed well posterior and should be approximately 3.5–4.5 cm in length. Healing will be best and the scar best concealed if it is made as a straight rather than line .

Patient considerations:

As with temporal incision placement, options for the placement of the occipital portion of the facelift incision should be discussed with the patient and
presented as a choice between two

imperfect alternatives:

  • a scar ‘hidden’ in the scalp and hairline displacement; or
  • a scar along the hairline with hairline preservation.

It is wise that the final decision about where the incision is located is made by the patient after

the advantages and disadvantages of each option have been discussed. It has been my experience that most patients are concerned by the prospect of occipital hairline displacement and recognize it as an objectionable sign that a facelift has been performed. When properly advised and given a choice, most consent to a hairline incision.


  • Planning modification of the SMAS,

All patients undergoing a facelift will benefit from some modification of the SMAS and a high posterosuperior advancement of the cheek SMAS serves as the fundamental step in rejuvenation of the face and avoidance of secondary deformities. SMAS advancement provides a natural appearing and long-lasting correction in the cheek and jowl and will consolidate the lower face.

  • Operative technique,
  • Skin flap elevation,
  • Flap dissection,
  • Incising the SMAS and flap elevation,
  • SMAS suspension,
  • Securing the superior margin,
  • Drain placement,
  • Skin flap repositioning and suspension,
  • Suture placement,
  • Skin flap trimming and closure


Complications include:

  1. Secondary facelift deformities such as objectionable temple, side- burn and occipital hairline displacement and scarring related to inappropriate skin tension, poor planning of incisions or performance of the surgery itself;
  2. Alopecia and/or skin flap necrosis due to imprecise flap dissection, rough flap handling, wound closure under tension, or tying sutures too tightly;
  3. General surgical complications such as hematoma, infection and nerve damage.

 Postoperative Care

  1. After all planned procedures have been completed and all incisions have been closed, the patient’s hair is shampooed, rinsed and conditioned. Failure to do this can result in matting and tangling that can be problematic in the postoperative period.
  2. Strips are applied.
  3. Patients are asked to rest quietly and apply iced compresses to their eyes for 15–20 minutes of every hour they are awake for the first 3 days after surgery. For most patients, edema peaks at about this time.
  4. Applying iced compresses to the cheeks, neck, or forehead has not proven necessary unless fat injections have been performed, and is generally not well tolerated by the patient.
  5. All patients are provided with oral analgesics, sleeping pills, antiemetic suppositories, bland ophthalmic ointment and artificial tears solution. They are required to use ophthalmic ointment each night for the first 3 weeks after surgery or until all signs of eye irritation have abated. Artificial tears are used throughout the day as needed.
  6. All patients are instructed to sleep flat on their backs, head elevated with a pillow for 2 weeks.
  7. Patients are asked to avoid salty, sour, and difficult to chew foods, and to abstain from alcohol for 2 weeks after surgery.
  8. Compression garment is applied after surgery and recommended to be used for 1 week, day and night.
  9. Patients begin a daily routine of showering and shampooing no later than 3 days after their procedures. This helps remove crusting about the suture lines, keeps incisions clean and bacteria counts down, and usually improves the patient’s general overall wellbeing. It also facilitates suture removal. Showering and shampooing are permitted and encouraged, even when drains are still in place.

 10 - Removal of drains and sutures,

The neck drain is typically left in place for 4–5 days .Sutures are removed in two visits over a period of 7 days.

 11 - Return to normal activities,

Patients are asked to set aside 2–3 weeks to recover from surgery. Patients who are doing well and not experiencing problems are allowed to return to light office work and casual social activity 3 weeks later. Patients are advised not to drive for the first 10 days after surgery and until they are feeling well, their vision is clear, and they are off pain medications. Patients are advised to avoid all strenuous and aerobic activity during the first few weeks after surgery, including heavy lifting, stooping, straining and bending forward. They are allowed to begin light exercise 4 weeks after surgery. 8 weeks after surgery they are allowed to engage in more vigorous activities, including most sports, as tolerated.