Journal of Aesthetic & Reconstructive Surgery

Description

The pursuit of facial rejuvenation has led to significant advancements in facelift techniques over the decades. Among these, the manipulation of the Superficial Musculo-Aponeurotic System (SMAS) has revolutionized the approach to surgical facelifts. The SMAS layer, a fibromuscular structure beneath the skin and subcutaneous tissue, plays a critical role in facial aging and sagging. Techniques targeting this layer provide longerlasting and more natural-looking results compared to older skinonly approaches. Additionally, innovations in single-incision facelifts have further advanced the field, offering patients less invasive options with reduced scarring and downtime. This article describes the evolution, techniques and outcomes of SMAS-based facelift procedures, as well as the growing role of single-incision developments.

Importance of the SMAS in facial rejuvenation

The SMAS, first described in the 1970s, is a continuous layer extending across the face and neck. It integrates the facial muscles, ligaments and overlying soft tissue, allowing coordinated facial expressions. As individuals age, the SMAS layer weakens and descends, contributing to jowls, deep nasolabial folds and loss of jawline definition. Early facelift techniques focused on tightening the skin alone, which often led to an unnatural, "pulled" appearance. By addressing the SMAS, surgeons are able to reposition deeper tissues, achieving a more natural lift that sustains longer-term results.

SMAS facelift techniques involve manipulation, suspension and plication of the SMAS layer to lift the underlying facial structure. Some of the most prominent approaches include: SMAS plication is one of the simplest methods, involving folding and suturing the SMAS layer without excision. It is less invasive, making it suitable for younger patients or those seeking moderate rejuvenation. Plication offers quicker recovery, though the results may not be as enduring as more complex techniques.

SMAS imbrication technique involves overlapping the SMAS without excising tissue, creating a layered lift. Imbrication can enhance both volume and structure in the midface and lower face regions. In more advanced aging, surgeons employ the extended SMAS technique, which involves elevating the SMAS and repositioning it along a wider vector. This approach addresses midface volume loss, jawline sagging and deep wrinkles comprehensively.

While traditional SMAS facelifts require multiple incisions along the hairline, preauricular area and occasionally under the chin, there is a growing trend toward single-incision procedures. These techniques are designed to minimize scarring and surgical trauma while still delivering robust results.

The minimal incision SMAS Lift is an innovative approach that combines small, strategic incisions with SMAS plication or imbrication. The incision, often limited to the preauricular region, allows access to the SMAS without extensive tissue dissection. This technique is ideal for patients with mild to moderate facial aging who desire shorter recovery times and reduced risks.

The single-incision temporal lift focuses on rejuvenating the upper face and midface. A small incision within the temporal hairline provides access to lift the SMAS and reposition soft tissue. This method avoids more extensive incisions around the ear and jawline, offering an excellent option for patients with isolated midface sagging.

Endoscopic single-incision SMAS techniques

The integration of endoscopic technology has greatly facilitated single-incision SMAS facelifts. Through a small incision (or a few short incisions) in the hairline or preauricular area, surgeons use an endoscope to visualize and elevate the SMAS layer. Endoscopic facelifts are less invasive and cause minimal scarring while allowing precise manipulation of deeper structures. Patients benefit from shorter recovery times and fewer complications, though the procedure is best suited for mild to moderate aging changes.

The evolution of SMAS-based facelift techniques has revolutionized facial rejuvenation by addressing deeper structural changes associated with aging. Traditional SMAS approaches provide durable and natural results, while singleincision innovations, such as the minimal incision SMAS lift and endoscopic procedures, offer less invasive options with reduced scarring and faster recovery. As technology and surgical expertise continue to advance, these techniques will further enhance patient outcomes, ensuring more customized, effective and patient-friendly approaches to facial rejuvenation. By combining artistry with science, surgeons are now able to restore a youthful, natural appearance while minimizing surgical footprints, setting a new standard in facelift surgery.