SMAS Plication Facelift

Article Author:
Kritika Joshi
Article Editor:
Eric Seiger
12/13/2018 1:53:16 PM
PubMed Link:
SMAS Plication Facelift


Facial rejuvenation techniques have increased in popularity over the past few decades and in complexity since the early 20 century. As of 2016, rhytidectomies are in the top five cosmetic surgical procedures performed in the United States, along with breast augmentation, blepharoplasty, liposuction, and rhinoplasty . Due to the effects of gravity and cutaneous changes of ageing, the process of developing facial rhytids is inevitable. Loss of collagen contributes to decreased skin turgor, and sunlight exposure exacerbates loss of skin elasticity. In one’s 60s, the buccal fat pad shrinks and there is resorption of the skull, with brow descent occurring earlier in the third to fourth decades of life [1]. As such, the most common patient demographics for elective facelift procedures are usually females ranging in age from thirties to late seventies.

Patients desiring improvement in overall loose skin, removal of rhytids, and those with unilateral facial palsy may request this procedure. Ideal patients are thin, fair-skinned, and middle-aged with moderate to severe skin laxity. Thicker skin and overweight patients tend to have a less than optimal clinical outcome [2]. The procedure is meant to provide improvements to the facial structure such as sharpening of the cervicomandibular angle and jowls, improved cheek and neck firmness, removal of neck bands, and decreased nasolabial folds.

The SMAS (superficial musculoaponeurotic system) plication technique evolved as a minimally invasive technique to provide an alternative to highly invasive procedures with as little downtime as possible. Developed by Swedish plastic surgeon Tord Skoog in the 1970s, it has become increasingly popular as a viable option for best aesthetic outcome [3]. There have been several variations on the technique. One entails re-suspending the SMAS, while others resect it, placate it, or a mix of the three. Plication is defined as a fold, process of folding, or state of being folded. The SMAS plication technique is ideal as it is a fine balance between surgical invasiveness, aesthetic outcome, and recovery time. It is a quick single-day procedure, and has been shown to be easily acquired by and easily taught to aesthetic surgeons. Studies have shown the procedure to provide high patient satisfaction and reproducible results, with low complication rates.


The surgical procedure begins with tumescent anesthesia infiltration into the subcutaneous field and optional conscious sedation. General anesthesia may be utilized, if preferred. Tumescent anesthesia involves introducing a large volume (up to 4L or more) of dilute local anesthetic, combined with normal saline, sodium bicarbonate to reduce stinging discomfort, and dilute adrenaline to minimize blood loss and lidocaine toxicity, into the subdermal fat plane producing temporary firmness, or tumescence, of the target area ([4]). Typically, a mixture of 3 mL .05% or 0.1% lidocaine, normal saline, and 1:100,000 epinephrine is used. The initial incision using a 15 blade begins at the temporal area anterior to the ear and runs into the post-auricular sulcus. The cut can be extended as needed to provide sufficient subcutaneous dissection for an acceptable vector for SMAS traction based on the individual patient. Hydrodissection may be used to create the subcutaneous tissue plane, minimizing flap injury. Care must be taken to avoid injury to the marginal mandibular branch of the facial nerve. At any point during the procedure, more anesthesia can be administered if needed.

The flap is then undermined and elevated by blunt dissection. The SMAS layer is identified as the fibrovascular layer anterior to the muscles and below the subdermis. Anteriorly, near the ear, the SMAS is thicker and thins as it spreads along the cheek. SMAS plication is then done using a 2-0 quill suture to achieve the desired lift, followed by absorbable 4-0 Vicryl and 5-0 Prolene sutures.

Hemostasis should be observed to avoid a hematoma. Closure of the wound involves lining the flap to the ear, cutting off excess skin, and closing the entire length of the incision from the temporal region to the post-auricular sulcus with skin staples or sutures (non-absorbable 5-0 nylon).

Patients are instructed to sleep upright for the first week to minimize edema, and are given a neck support for one to two weeks. The neck can remain tight for up to three weeks. Sutures are removed on day seven, and patients are seen at three and six weeks. Depending on physician preference, medication is prescribed for pain control for at least the first week post procedure.


The most common complications of a SMAS plication include the following:  hematoma, transient facial nerve motor dysfunction, delayed wound healing, scar hypertrophy, areas of alopecia temporarily where incision is made, surface irregularities that may require fat transfer, skin flap necrosis, infection, and earlobe distortion. Patients may also experience ecchymosis and edema, which should abate by day fourteen but may persist for up to six weeks. Pain and tenderness is an expected post-procedure event.

Clinical Significance

This technique differs in that it includes multiple sutures for a dual-layer SMAS plication and resection of excess infra-auricular SMAS. An advantage to this technique over others is that the scar is hidden within the hairline with a vertical incision, rather than passing anterior to the hairline risking sideburn elevation and a visible scar. The post-auricular extension is important to avoid tissue redundancy that can contribute to additional recovery time. This procedure also avoids the possible need for an additional blepharoplasty incision to avoid lateral canthal crowding as seen with the MACS (Minimal Access Cranial Suspension) procedure, which is briefly discussed below. Lastly, since most of the tension is in the SMAS and not on skin, both tissue redundancy and stretch are avoided.

In comparison, the MACS lift is a well-established form of a face lift, but has limitation with respect to improved neck outcomes. It is a short scar rhytidectomy with vertical suspension of the facial tissue. The recovery time with a MACS procedure is shorter than a SMAS plication with stable results; however, it does not fully address the neck or the lateral periorbital areas. There is also usually visible scarring as the incision is made anterior to the temporal hairline.

Enhancing Healthcare Team Outcomes

Face-lifts, though a minor procedure relative to other larger scale plastic surgeries, are still a surgical procedure and require a team performance to ensure successful outcomes. The performing physician must carefully evaluate the individual patients' candidacy and ability to recover with successful and optimal results. Some patients may not be suitable surgical candidates and other non-invasive procedures such as Ultherapy or injections with dermal filler might produce the desired results. Clear communication of surgical outcomes and complications must be addressed between physician and patient to ensure a good outcome. Though complications are not life threatening and rates are low, an interprofessional team approach in the setting of SMAS plication procedures involving trained surgical technicians can provide for swift execution with minimal to no error minimizing complications altogether (Level of Evidence IV). 

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      Contributed by Eric Seiger, DO


[1] Kurosumi M,Mizukoshi K, Principal component analysis of three-dimensional face shape: Identifying shape features that change with age. Skin research and technology : official journal of International Society for Bioengineering and the Skin (ISBS) [and] International Society for Digital Imaging of Skin (ISDIS) [and] International Society for Skin Imaging (ISSI). 2018 May     [PubMed PMID: 29139154]
[2] Berry MG,Davies D, Platysma-SMAS plication facelift. Journal of plastic, reconstructive     [PubMed PMID: 19328757]
[3] Zimbler MS, Tord skoog: face-lift innovator. Archives of facial plastic surgery. 2001 Jan-Mar     [PubMed PMID: 11176723]
[4] Klein JA,Jeske DR, Estimated Maximal Safe Dosages of Tumescent Lidocaine. Anesthesia and analgesia. 2016 May     [PubMed PMID: 26895001]