What are the Extended and High SMAS Techniques?

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With Mitz and Peyronie who described the anatomical layer of Superficial Musculo-Aponeurotic System (SMAS) in 1976, innovation in facelift surgery techniques followed. Two enduring techniques which yield reliable, as well as natural long lasting results, are the extended and the high SMAS techniques.

Extended SMAS Technique

The extended technique was first popularised by Dr Stuzin from Florida in the United States. The skin incision remains similar to all other facelift procedures. The incision starts in the temporal hairline (just above the sideburns) or just in front of the ear and the sideburn extending behind the ear and depending on the type of incision (short scar or long scar), extending into the hairline. After widespread undermining of the skin towards and very close to the nose and the corner of the mouth, the SMAS is accessed on the zygomatic or the cheekbone skeleton, and is undermined all the way towards the apple of the cheek (Fig 1). Resuspension of the undermined SMAS against the skeleton or underlying stable tissues then achieves the lift. Finally, the skin is closed over the lifted SMAS.

Figure 1 (The extent of the skin undermining and the neck incision in an extended or high SMAS Facelift technique).

The advantage of this technique is that it is a powerful tool in addressing ageing and the descent of the mid cheek. Combined with neck rejuvenation and eyelid lift techniques, it consistently provides reproducible, natural long lasting results. The technique requires broad and deep experience including a very good understanding of the anatomy of the SMAS. The learning curve is rather steep and the facial nerve is under threat during surgery. The widespread facelift surgery skin flaps are ultimately resuspended with the excess being excised. Post-operative recovery shows a similar profile to other SMAS based techniques described thus far in the series. Relatively prolonged post-operative swelling and risk of partial skin flap loss are amongst the drawbacks of the surgery (Fig 2).

Figure 2 (Extended SMAS technique for access to the midface and cheek).

High SMAS Technique

Another SMAS facelift surgery technique popularised by the gifted Texan surgeon Fritz Barton, similarly yields powerful mid cheek results, whilst addressing the rest of the face and when combined with neck lift and eyelid procedures, produces excellent long lasting natural outcomes. In this technique after widespread undermining of the skin towards the nose, corners of the mouth and extending into the neck, the SMAS is accessed above the zygomatic or cheekbone in the temporal region. After undermining towards the apple of the cheek, the SMAS is resuspended against the deep temporal fascia achieving a lift. The facelift skin flaps are then closed after excision of the excess skin.

Similar to the extended SMAS technique, the widespread undermining of the facelift skin flaps does mean a prolonged post-operative swelling and there is risk to the facial nerve branches even in the most experienced of hands. In our next blog we will be discussing composite face and neck lift surgery.

Figure 3 (High SMAS facelift technique for access to the mid-face and cheek).


All illustrations are reproduced with permission Farhadieh RD, Bulstrode N, Cugno S: Plastic and Reconstructive Surgery: Approaches and Techniques,Wiley & Blackwell, London, UK, 2015.

Dr Ross Farhadieh
Dr Farhadieh is an internationally renowned Australian qualified and trained Plastic Surgery. He holds fellowship qualifications in Plastic Surgery from Royal Australian College of Surgeons, Royal College of Surgeons (England) as well the European Board of Plastic Reconstructive Aesthetic Surgery. He has multiple clinical subspecialty fellowships in Cosmetic, Pediatrics as well as Microsurgery from World Leading institutes in London.
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