SMAS Plication Facelift

Facial rejuvenation techniques have increased in number and complexity over the past several decades, with demand for these procedures steadily increasing since the early twentieth century. Since 2016, rhytidectomy (facelift) has been in the top 5 most commonly performed cosmetic surgical procedures in the United States, along with breast augmentation, blepharoplasty, liposuction, and rhinoplasty. Patients request facelifts because, with advancing age, loss of collagen decreases skin turgor, and chronic sunlight exposure contributes to decreased skin elasticity. In the third to fourth decades of life, soft tissue brow descent begins, with buccal fat pad descent and atrophy, as well as resorption of facial bone occurring in the sixth to seventh decades of life and beyond. For this reason, the most common patient demographic for elective facelift procedures is females ranging in age from their thirties to late seventies. Patients desiring improvement in skin smoothness and jaw contour, and those with unilateral flaccid facial palsy, may benefit from facelifting. For less invasive rhytidectomy techniques, such as superficial musculoaponeurotic system (SMAS) plication approaches, ideal patients are thin and possess mild to moderate skin laxity and jowling without major ptosis of the malar fat pads or deep nasolabial folds (see Superficial Musculoaponeurotic System Plication Procedure). Thicker-skinned and overweight patients tend to have less than optimal clinical outcomes with these more conservative procedures. SMAS plication facelifting aims to improve facial appearance by sharpening the cervicomandibular angle, reducing the jowls, and improving the jawline's definition. The SMAS plication facelifting technique evolved to provide an effective means of suspending the soft tissues of the face beyond simply tightening the skin. Developed by Swedish plastic surgeon Tord Skoog in the 1970s, it has become increasingly popular as a facial rejuvenation option. Several variations of the technique have been reported to provide resuspension of the SMAS in a favorable vector. Some surgeons elevate SMAS flaps and transpose them; some prefer plication, and some imbrication. Plication is the folding of the SMAS with subsequent suturing to apply tension; imbrication is the removal of a segment of SMAS with overlapping of the cut edges and closure of the defect serving to resuspend the tissue. SMAS flap facelift techniques are generally performed as outpatient procedures and are easily taught to trainees. While all operations risk the development of complications, rates of adverse events occurring in SMAS facelifts are low, and patient satisfaction is generally high.