Clinical Application of the High Superficial Musculoaponeurotic System for Facial Rejuvenation in Chinese Patients

Abstract

Background:

Face lift surgery can improve facial sagging and reestablish a youthful relationship between the soft tissues and the underlying skeleton. The early manifestations of aging in the periorbital region include sagging of the lateral eyebrows, which can lead to changes in facial expression and the appearance of fatigue and anxiety. In this study, we investigated the clinical outcomes of superficial musculoaponeurotic system (SMAS) face and neck lift combined with a subperiosteal brow and tail lift in a specific cohort of patients from China.

Methods:

One hundred fifty patients underwent high-SMAS face and neck elevation between September 2018 and September 2022; 28 cases were combined with subperiosteal brow-tail elevation. SMAS separation was performed upward, flat with the lateral canthus; downward to approximately 2 cm below the mandibular margin; and inward over the zygomaticus major muscle, extending forward medially to the prezygomatic and masseteric spaces. Next, the temporal ridge was moved medially by subperiosteal stripping, achieving a full separation of the periorbital and frontal-temporal migratory zones. The temporoparietal fascia was lifted and fixed tension-free to the deep temporal fascia until the tail of the eyebrow was effectively elevated.

Results:

Most patients achieved facial rejuvenation, and no permanent damage to the facial nerve or serious complications, such as flap necrosis, were observed.

Conclusions:

Combining a high-SMAS flap with subperiosteal elevation of the brow tail restores youthfulness in aging candidates. As the follow-up period of the study was limited, additional time is required to determine the most appropriate face lift method.

Takeaways

Question: What are the clinical outcomes of high superficial musculoaponeurotic system (SMAS) face and neck lift combined with a subperiosteal brow and tail lift?

Findings: We investigated the clinical outcomes of SMAS face and neck lift combined with a subperiosteal brow and tail lift in a specific cohort of patients from China. Most patients achieved facial rejuvenation.

Meaning: Combining a high-SMAS flap and subperiosteal elevation of the brow tail restores youthfulness to aging candidates.

INTRODUCTION

Facial aging is a major challenge in the aging process, as mimetic muscle contraction leads to the formation of wrinkles. The soft tissues of the midface, including the zygomatic fat pads, sag with increasing age, leading to the deepening of nasolabial folds, a “bag-like” appearance at the outer corners of the mouth, the formation of marionette lines, wider cheeks, and loss of definition in the neck and jawline. The facial shape changes from an inverted triangle to a positive triangle.^1–3 Early manifestations of aging in the periorbital region include sagging of the lateral eyebrows. These facial changes often result in altered facial expressions and the appearance of fatigue and anxiety.^4–6 Techniques such as high superficial musculoaponeurotic system (SMAS), extended SMAS, and finger-assisted malar elevation enhance the correction of facial sagging at the soft tissue level. Additionally, subperiosteal lifting, which involves extensive subperiosteal detachment, restores a youthful harmony between the soft tissues and the underlying skeleton.^7,8 Oriental faces are typically wide and flat with short zygomatic arches and flat zygomatic prominences. In contrast, western facial features often include long zygomatic arches and small zygomatic prominences. Additionally, oriental skin and retention ligaments are usually thicker and stiffer, which can make it difficult to achieve good outcomes during cosmetic surgery.⁹ The lateral bundle of the orbicularis oculi and the platysma constitutes the descending facial muscle.¹⁰ The frontalis muscle acts mainly against the medial brow, with diminished strength against the lateral side; therefore, the progression of frontal aging and brow-tail descent is quicker.^4–6 Traditional methods to improve the brow-tail descent include surgical incisions above and below the brow; complications of this approach include persistent asymmetries, an unsightly scar, and anesthesia if the sensory nerves are disrupted by dissection in the submuscular plane.¹¹Although numerous previous studies have focused on the SMAS face and neck lift in patients from various biogeographical regions, there has been no specific study on the application of this technique in Chinese patients.

PATIENTS AND METHODS

Participants

The inclusion criteria were as follows: all candidates had varying degrees of facial aging manifestations and were willing to share medical records for scientific purposes. Patients whose records were insufficient for the present study and those who did not provide permission for the use of their clinical data were excluded. Candidates with unrealistically high demands for postoperative results were also excluded; long-term smokers and candidates taking anticoagulant medications, such as aspirin, were asked to discontinue the medication for more than 2 weeks preoperatively. Based on the inclusion and exclusion criteria, the records of 150 patients (132 women and 18 men) were ultimately included in the study. The median age of the patients was 46.8 years. All the included patients completed the Global Aesthetic Improvement Scale before surgery and during their final postoperative visit. The follow-up period was between 6 and 24 months (median, 15.1 mo). The same surgeon performed all the procedures between September 2018 and September 2022. All the procedures were performed under general anesthesia. This research study was approved by the Affiliated Friendship Plastic Surgery Hospital of Nanjing Medical University. The present study was conducted in accordance with the standards for biomedical research on human subjects set by the Declaration of Helsinki. Before surgery, all the patients were informed that their photographs could be published for scientific purposes. All the patients whose records were used in the present study have provided written informed consent (Table 1).

Table 1.

Demographics of the Patients

Patient Number (Combined Brow Lift)	Female (Male)	Age, y	Follow-up Period, Mo	Exceptionally Improved	Much Improved	Improved	Unaltered	Worsened
150 (28)	135 (15)	46.8 (SD 7.72)	15.1 (SD 3.95)	81	29	24	16	0

Surgical Methods

For the procedure, each patient was moved into the operating room, where the “sentinel vein” on the temporal crest was marked, and the patient was asked to clench their teeth and touch the outline of the temporal muscle and crest of the forehead. The temporal fixation point was set at the projected line between the nose and the lateral canthus in the temporal region. After the patient was given intravenous sedation, a tumescent solution consisting of 0.1% lidocaine with epinephrine (1:1,000,000) was infiltrated to both sides of the face, with approximately 120–150 mL administered per side. An incision was made within the temporal hairline, the tragal margin, and the occipital hairline, and a skin flap was elevated. (See figure, Supplemental Digital Content 1, which displays the design of the drawn line and the extent of skin separation (A). B, Completion of skin separation. C, Temporoparietal fascia fixation in the deep temporal fascia to raise the brow tail. D, E, and F, Extent of the proposed separation of the SMAS subfascial and subfascia using direct visualization. G, Completion of SMAS flap separation. H, Completion of the fixation of the SMAS-platysma flap to the mastoid fascia. I, Completion of the fixation of SMAS-orbicularis oculi flap to the deep temporal fascia, http://links.lww.com/PRSGO/E29.)

The separation range of the skin flap included the anterior 6 cm of the tragus and the anterior 7–8 cm of the earlobe, extending forward along the mandibular border and vertically down to the first neckline (Supplemental Digital Content 1, http://links.lww.com/PRSGO/E29). The skin and subcutaneous tissues were incised, and curved blunt tissue scissors were used to achieve a subcutaneous blunt separation along the drawn line. In the temporal part of the line connecting the nasal ala and the lateral canthus, the temporoparietal fascia was incised to the superficial layer of the deep temporal fascia. The periosteal peeler was used to bluntly peel over the supratemporal septum to the frontal subperiosteum. The temporal attachment and the thickened areas on the orbit’s lateral side were peeled to appropriately separate the temporoparietal fascia and to close the temporoparietal fascia using 3-0 polyester suture (Ningbo Cheng-he, China) to the appropriate position of the deep fascia. The eyebrow was visualized, and the temporoparietal fascia was separated and fixed by 3/0 braided threads. With the deep fascia in the appropriate position, the eyebrow tail was lifted appropriately (Supplemental Digital Content 1, http://links.lww.com/PRSGO/E29); a line was drawn in the lateral canthus with a marker pen, and the superficial temporal fascia was incised in the lateral canthus (Supplemental Digital Content 1, http://links.lww.com/PRSGO/E29). The zygomatic ligament was dissected downward and forward under the SMAS, and the orbicularis oculi muscle was visible on the upper part of the lateral canthus. The zygomaticus major muscle was visible in the central portion, and the buccal fat pad was visible in the lower part. If the lifting was not effective, it was dissected inwardly and crossed over the zygomaticus major muscle, and the main zygomatic ligament was then dissected bluntly to increase the mobility of the SMAS flap (Supplemental Digital Content 1, http://links.lww.com/PRSGO/E29). We separated the platysma-auricular ligament and suspensory platysma ligament, and peeled off the SMAS flap below the mandibular margin. (See Video [online], which displays the separation range of the SMAS.)

Video 1. The separation range of the SMAS.

Download video file ^{(4.4MB, mp4)}

However, if the herniated buccal fat was too large, a portion of the buccal fat pad was appropriately removed, and the stump was fixed in the depression of the lower edge of the zygomatic arch by pulling it tightly backward and upward with a 3/0 braided suture. The orbicularis oculi muscle flap was cut longitudinally, and the platysma muscle was cut 2 cm below the edge of the mandibular margin. The SMAS-orbicularis oculi muscle flap was pulled upward and fixed with a 3/0 braided suture to the deep temporal fascia. The SMAS-platysma flap was fixed by passing the earlobe suture to the mastoid process, and intermittent sutures were tightened to fix the SMAS fascia (Supplemental Digital Content 1, http://links.lww.com/PRSGO/E29); the visual field of the facial morphology was satisfactory. Intermittent sutures were sutures placed at spatial intervals rather than continuously. The right side of the skin was laid flat, excess skin was excised, and electrocoagulation hemostasis was performed. Another incision under the posterior ear flap was performed to position a drainage tube, and temporary drainage tubes were fixed with a 5/0 braided suture. The skin incisions were closed with interrupted 6/0 nylon sutures. The contours of the face postoperatively were symmetrical and met the desired aesthetic goals.

Postoperative Evaluation

The patient’s satisfaction with the surgical procedure and outcomes was evaluated 6 months to 2 years postoperatively. Patient satisfaction was assessed using a validated tool, the Global Aesthetic Improvement Scale. The subjective satisfaction of each patient was graded as follows: exceptionally improved, much improved, improved, unaltered, and worsened. Facial improvements included effects on eyebrow ptosis, nasolabial folds, the lifting effect of the malar fat pad, and clarity of the jaw margin. The median age of the patients was 46.8 years (range: 36–64 y; SD 7.72); the follow-up period was between 6 and 24 months (median: 15.1 mo). The same surgeon performed all the procedures and assessed patient satisfaction during the final postoperative visit. Of the patients, 81 reported exceptional improvement, 29 were much improved, 24 found the results improved, 16 reported being unaltered, and no worsened results were reported (Table 1). No patient required revision surgery. One patient presented with a mandibular marginal branch injury, which gradually resolved 6 months postoperatively, and 2 patients experienced a postoperative hematoma. However, no other complications, such as skin necrosis, were observed. (See figure, Supplemental Digital Content 2, which displays a 51-year-old female patient 12 months after a high-SMAS face and neck lift combined with subperiosteal brow-tail lift. Preoperative images include frontal view (A), left lateral view (B), and right lateral view (C). Postoperative images include frontal view (D), left lateral view (E), and right lateral view (F), http://links.lww.com/PRSGO/E30.) (See figure, Supplemental Digital Content 3, which displays a 51-year-old female patient 24 months after a high-SMAS face and neck lift. Preoperative images include frontal view (A), left lateral view (B), and right lateral view (C). Postoperative images include frontal view (D), left lateral view (E), and right lateral view (F), http://links.lww.com/PRSGO/E31.)

DISCUSSION

In the 1970s, the discovery of the SMAS led to improvements in surgical techniques such as folding, suturing, and partial excision, which resulted in long-lasting outcomes.¹² Face lift surgery effectively reverses the signs of aging. Anatomically, (1) the orbicularis oculi and the platysma area are larger in Chinese individuals than in westerners; (2) the platysma muscle, the largest descending muscle, is responsible for aging in the cervico-mandibular angle; and (3) the outer lower half of the orbicularis oculi muscle is a descending muscle.^9,10 The medial part of the lateral limb of the orbit is the mimetic muscle area, and the lateral area is the masticatory area. Aging in these areas is relatively slow. Most mimetic muscles are located in the superficial fascia of the periorbital and perioral regions. The soft tissues surrounding the perinasal, perioral, and chin protuberances tighten the facial soft tissues like an accordion, including the orbital and perioral sphincters. Midface laxity, accompanied by ligamentous and space enlargement, is characterized by sagging of the soft tissues (including the malar fat pads) and deepening of the nasolabial folds. Patients in China often describe this as sagging of the malar fat pad. The angle of the platysma muscle maintains perioral rejuvenation, and during the aging process, the platysma-auricular ligament lengthens, whereas the cervico-mandibular angle changes from sharp to obtuse. The suspensory platysma ligament functions to pull the platysma muscle toward the bony surface of the mandible, maintaining the acute angle of the jaw and neck. Sagging of the skin and the platysma muscle disrupts the curves in this region. The masseteric cutaneous ligament at the anterior border of masseteric space, below the buccal fat, weakens and expands, leading to an enlargement of the masseteric space, further provoking the sagging of the buccal fat pads and the formation of jowls and marionette lines at the outer corners of the mouth.¹ Anatomically, the lateral frontalis muscle ends at the temporal fusion line (superior temporal septum), and there is no elevator muscle to counteract the depressor muscle of the lateral brow. This, along with gravity, explains the sagging of the lateral portion of the brow. The SMAS flap, located below the zygomatic arch in White people, can lift the range of the cheek and neck, although the malar fat pad in the face has a limited lifting effect. The face lift in Chinese patients is a unique procedure because of the differences in the skeletal structure and soft-tissue quality of Chinese patients compared with White patients. The anatomy of the Chinese face is unique, with a wider bizygomatic distance and a more abrupt transition from the lateral to the anterior face over the body of the zygoma; effective lifting of the midface requires separation of the SMAS beyond the zygomatic prominence through a specialized approach using a high-SMAS flap positioned flat with the lateral canthus to effectively address the zygomatic prominence and achieve the desired facial contour.^7,8,13 Additionally, the tail of the brow can be lifted by separating the temporoparietal fascia above the deep temporal fascia, as well as by separating the superior temporal septum and the lateral orbital thickening area.¹³

Laxity of spaces is a significant contributor to facial aging, and the facial ligaments form the margins of these spaces under the SMAS plane.¹⁴ The absence of structures within these spaces allows for safe dissection, reducing the risk of bleeding, bruising, or facial injury from nerve damage. Aging of the interspaces leads to the deepening of the zygomatic pockets, lateral sacs of the corners of the mouth, and the deepening and lengthening of the marionette lines. The masseteric space, surrounded by ligaments, is a bloodless plane. After releasing the restrictions of the masseteric ligaments, buccal fat pads can be observed in the buccal space. Furthermore, dissection of the masseteric ligaments during face lift surgery is highly effective for treating signs of aging in the medial zone,¹⁵ including the nasolabial folds. Care should be taken not to injure the buccal branch of the facial nerve. The buccal fat pads are enlarged by resecting a portion and securing the stumps in the depressed area.

Face lift surgery involves dissecting the “wall” from the spaces, merging this space into another, while simultaneously separating the space and lifting it; this is the preferred method for the treatment of aging. In patients with an enlarged parotid gland, the gland fascia is tightened by suture or bipolar electrocoagulation. However, attention should be paid to the trunk of the facial nerve between the superficial and deep lobes when suturing. Biplane face lift surgery involves preparing a high-SMAS flap and a temporoparietal fascia flap, with separation of the supratemporal septum and thickening of the lateral brow. The upper SMAS flap is obtained by dissecting the descending muscles of the face (lateral orbicularis oculi and platysma); the high-SMAS flap is then used to flatten the fissure of the eye. During surgery, the SMAS is detached from the surface of the middle temporal fascia. This includes detaching the zygomatic arch ligaments and the medial zygomaticus muscle-restricting ligament as much as possible. Detaching the zygomaticocutaneous ligament, which is attached to the zygomatic protuberance, allows for effective elevation of the SMAS flap. The SMAS-orbicularis orbicularis muscle flap can then be firmly fixed to the deep temporal fascia.^15,16 In this way, the position and curvature of the youthful “apple muscle” appearance are restored and form an “S” curve when viewed from the side, which improves the aging of the vortex at the corners of the mouth to a certain extent. Filler may be applied to the nasal base with the SMAS fascia to further improve the nasolabial folds. The platysma muscle was dissected 2–3 cm below the mandibular margin to free the SMAS from the downward force, and the lower part of the middle face is lifted up vertically. The SMAS-platysma muscle flap is fixed on the fascia of the sternocleidomastoid muscle of the postauricular mastoid region, and the soft tissues are compressed to rebuild the platysma suspensory ligament, so that the mandibular angle is exposed and clearly defined. The platysma muscle changes from a descending muscle to a lifting muscle. The early appearance of a slight tissue buildup on the temples and zygomatic prominences after the completion of SMAS-orbicularis oculi flap and SMAS-platysma flap fixation usually recovers after 3–4 weeks.

There are some limitations to this study that need to be considered. First, the surgical incision can result in varying degrees of scarring, making it challenging to conceal the marks, especially in patients with scarred skin. Second, the effectiveness of the treatment is constrained by factors such as nasolabial folds, eyelids, and vertical wrinkles around the mouth. Finally, the procedure involves dissection, which coul.d potentially lead to complications such as skin roughness, hematoma, nerve damage, baldness, skin necrosis, and hyperpigmentation, among others.^17,18

CONCLUSIONS

Many prevalent face lift techniques, such as the extended SMAS, high-SMAS, and finger-assisted malar elevation procedures, are recognized for their effectiveness in enhancing the midface and lower face.^19,20 However, the performance of face lift techniques developed primarily for White patients may differ in Chinese patients. This characteristic of the Chinese face results in loss of effective mechanical lifting force in the anterior face for forces applied from a SMAS flap flat with the zygomatic arch. It is, therefore, mechanically necessary for the lifting and fixation to be applied more upwardly in Chinese patients. To optimally fulfill these requirements and circumvent the challenges unique to the Asian anatomy, we have described a face lift procedure incorporating a high-SMAS technique flap flat with the lateral canthus and a partial brow lift to address the aging Chinese face. However, face lift surgery is more demanding on the operator, who must have a thorough understanding of facial anatomy to avoid postoperative complications. Although our study provides valuable insights into face lift procedures for Chinese patients, there is now a need for further studies to define appropriate methods for facial rejuvenation in this specific patient population.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.