PLASTIC AND RECONSTRUCTIVE SURGERY 2002;110:667-671
Purse String-Formed Plication of the SMAS with Fixation to the Zygomatic Bone
Ziya Saylan, M.D.; Dusseldorf, Germany
The superficial musculoaponeurotic system (SMAS) operation revolutionized face-lift procedures. The idea of having one direction of traction with suturing and fixation of SMAS to a stable structure is gaining popularity. The author´s contribution is the fixation of the SMAS and the extension of the supraplatysmal plane to the zygomatic bone periosteum to achieve stable traction and fixation. This procedure has not been described before in medical literature. The purse string-formed plication of the SMAS is a procedure in which the soft tissue (SMAS, parotid fascia, and the extension of the supraplatysmal plane) is plicated and fixed to the periosteum of the zygomatic bone. This superficial operation avoids entering the deeper planes, which could result in severe complications. The procedure fills the cheeks and gives a more natural look than standard face lifts. A total of 250 patients underwent this procedure. The suspension achieved seemed to be more stable than some SMASectomy techniques. Complication rates and recovery times were low. The purse string-formed plication of the SMAS is a safe, quick, and simple procedure with effective results suitable for younger patients with good skin conditions.
Almost three decades ago, Skoog1 demonstrated that dissection could be performed beneath a layer later to become known as the superficial musculoaponeurotic system (SMAS), and a new era in face-lift surgery began. In 1977, Owsley2 reported plicating the SMAS tissue, which gave an optimal traction of the lower facial tissues. During the following years, different surgeons chose to use the SMAS in different ways, but typically a single large flap was elevated over the lower cheek. In the early 1980s, Jost and Lamouche3 published articles on resection and even segmentation of the SMAS flaps pulling in different directions. Recently Baker4 published his work on short scar face lift with lateral SMASectomy.
I describe a technique that requires a modified SMAS plication in purse-string form.5 At the same time, the extension of the supraplatysmal plane6 is pulled together to achieve a better result of the neck. The soft tissue (the SMAS, the parotid fascia, and the extension of the platysma of the submandibular region) is pulled together by means of a purse string-formed suture with multiple small bites (to stay superficial) that is then fixed to the periosteum of the zygomatic bone with a periost needle.
The initial description of fixation of the SMAS and the parotid fascia to the periosteum of the zygomatic bone is based on the beliefs that two sling-formed sutures sutured to the periosteum of the zygoma can suspend the lower facial tissues and that the extension of the supraplatysmal plane6 would be the most appropriate solution to a lower face lift.5 I strongly believe that greater stabilization of the SMAS is required during a face lift to achieve better and longer-lasting results. To ensure further stability of the lower face and to correct the neck, the extension of the platysmal muscle is also sutured and suspended and fixed to the zygoma.
Patients and Methods
Technique: After the skin incision and coagulation of the bleeding vessels, the skin is raised and undermined below the subcutaneous fat tissue and above the SMAS. The supraSMAS region and the parotid fascia layers will be seen. The suturing starts from the periosteum of the zygomatic bone approximately 3 to 5 cm away from the tragus. The surgeon has to feel the bone, and, if necessary, make a small incision and free the periosteum. This place is called "No Man´s Land" (Fig. 1). There are no vessels and nerves in this region. A major injury in trained hands is not possible. The SMAS plication is performed with two sutures of 2-0 Ethibond (Ethicon, Norderstedt, Germany). The first suture (U suture) is vertically inserted between the level of zygoma and the extension of the supraplatysmal plane below the mandibular rim. This suture will pull the neck higher and tighten it. The second suture (O suture) is inserted with an angle of 45 degrees to pick up the fascia of the parotid gland and SMAS and pull the lower face posteriorly and superiorly (Fig. 2 and Fig. 3). Undermining more than 6 to 8 cm away from the tragus toward the midline is not needed. The author believes that less undermining will pull the soft tissue as a whole piece (en bloc) vertically. The suturing is done in multiple small bites and superficially. The soft tissue is, thereby, pulled and tightened up like a purse string and sutured by a nonresorbable material at the periost of the zygomatic bone.
Fig. 1. The place of fixation for the sutures is the periosteum of the zygomatic bone, which is free from vessels and nerves.
Fig. 2. The U-shaped and O-shaped purse-string sutures pulling the SMAS, the extension of the supraplatysmal plane, and the parotid fascia upwards (left). The location of U and O sutures (purse strings) externally (right). Inserting the suture below the mandibular rim collecting the extension of the supraplatysmal plane (left). Collecting the SMAS and the parotid fascia like a purse string (small and superficial bites)
Fat should not be removed immediately from the jowls during dissection of the supraSMAS plane. The jowl fat pads can be liposuctioned openly with the vacuum cleaner technique. A better method is the fixation of the fat pad of the hanging cheeks to a higher position at the level of the cheeks, which can be an advantage in most cases, giving the face a youthful and natural look. Hoefflin6 observes in regard to this procedure that "pulling on the SMAS is like repositioning a living room sofa by pulling on the carpet. It´s easier to just pick up the sofa and position it where you want it." This procedure is called fat repositioning.
Two hundred and fifty patients were included in this study. Twelve of the patients were male (4.8 percent) and 238 were female (95.2 percent). Three cases (1.2 percent) of temporary facial nerve palsy, which resolved quickly, were observed in patients with a secondary face lift. This palsy affected the temporal branch of the facial nerve that is medial to the arch of the zygomatic bone (and which can be injured if hidden in scar tissue). Two patients (0.8 percent) developed hematomas, one of which had to be aspirated. No cases of skin necrosis or infection occurred. Forty-four patients (17.6 percent) complained of feeling tension and pain in the pretragal area; however, this went away after 3 weeks. A temporary soft-tissue dimpling beneath the ear lobe (lasting 8 to 12 weeks), caused by the traction of the platysma, was experienced by most of the patients (190 patients, 76 percent). Liposuction of the soft tissue with a sharp cannula can be used to treat the dimpling if the patient is unhappy, but this could also negatively influence the overall result.
Advantages of this Method
The U suture picks up the platysma and achieves a much better neck result.
The O suture collects the SMAS and the parotid fascia like a purse string, without major undermining.
There is low risk of facial nerve injury resulting from tightening of the SMAS, which is achieved by means of a purse string-formed plication with superficial bites and minimal undermining.
The direct vertical pull of the aponeurosis achieves a natural look to the face.
The fixation of soft tissue to cheekbones gives an extra fullness to the cheeks that sometimes makes a malar implant unnecessary.
A superficial (supraSMAS) dissection leads to less bruising and swelling.
The operation is short and has a quick recovery time.
I was not able to find any disadvantages to this technique.
This is a procedure in which the soft tissue (SMAS, parotid fascia, and the extension of the supraplatysmal plane) is plicated and fixed to the periosteum of the zygomatic bone. A deep dissection is unnecessary. The suspension achieved is, in my opinion, more stable compared with some SMASectomy techniques. The purse string-formed plication of the SMAS is a safe, quick, and simple procedure with effective results suitable for younger patients4 (Fig. 4, Fig. 5 and Fig. 6) with good skin conditions. Complication rates and recovery times are low. The procedure fills the cheeks and gives a more natural look than standard face lifts. Some young surgeons may be put off by complex procedures used for face lifts, such as deep-plane, subperiosteal, and composite rhytidectomies.7 The deeper layers are not for beginners, they are risky and more extreme. This superficial procedure is a much safer operation and avoids entering the deeper planes that could result in severe complications.