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Elongated, deep SMAS flap improves cheek lift


Robert M. Dryden, M.D., F.A.C.S.
San Diego — An elongated inverted, L-shaped deep SMAS flap provides the benefit of additional cheek elevation in rhytidectomy in addition to lifting the ptotic lower face and anterior cervical soft tissue, according to Robert M. Dryden, M.D., F.A.C.S.

The cheeklift is achieved by initiating the SMAS flap 1 cm superior to the zygomatic arch, says Dr. Dryden, who spoke on the topic at the annual meeting of the American Academy of Cosmetic Surgery here.

"Starting the incision above the zygomatic arch is the key to improved cheek lift," says Dr. Dryden, clinical professor of ophthalmology, University of Arizona, and in private cosmetic surgery practice in Tucson.

"With an elongated flap, the midfacial SMAS becomes part of the flap to be suspended over the zygoma," Dr. Dryden says. "The apex and posterior limb of the flap are superior to the zygoma, so the suspension and fixation sutures are placed in an area where the SMAS contributes to elevating the upper part of the cheek unlike a procedure where the SMAS dissection is beneath the zygoma."

Modified procedure The technique begins with standard periauricular rhytidectomy incisions, infiltration of local anesthetic solution with epinephrine, infusion of a tumescent solution into the subcutaneous tissues and undermining of the skin flap.

The SMAS incision is initiated 1 cm anterior to the skin incision, and the horizontal limb of the L-flap extends anteriorly to the level of the orbicularis and as thinly as possible. The proximity of seventh-nerve fibers is indicated by electrocautery neuromuscular stimulation, he explains. When in the area of underlying seventh-nerve fibers as indicated by muscle contraction, great care must be exercised.

After elevation, approximately 1 cm to 1.5 cm of SMAS can be overlapped, and the excess is excised, he continues. The SMAS is sutured with 4-0 polypropylene running sutures in a superoposterior direction for enhanced cheek lift, he adds.

Although it requires greater care, Dr. Dryden prefers imbrication to plication of excess SMAS.

"I believe it produces a cleaner facial contour that appears more natural without the excess tissue," he tells Cosmetic Surgery Times.

Seventh nerve is vulnerable There is one potential complication in using this modified procedure, according to Dr. Dryden.

"The disadvantage is that there is more risk to the seventh nerve, so you have to be very careful to stay very superficial," he says. "And you must use electrosurgical dissection, because electrosurgical dissection indicates that you're getting near the seventh-nerve fibers."

The flap is dissected using monopolar cutting current and a Colorado needle. As dissection approaches branch fibers of facial nerves, the electric current stimulation causes twitching of innervated muscles in the vicinity, providing warning of potential damage to vital structures, Dr. Dryden notes. The superficial facial nerve fibers in this area can thus be carefully avoided, he says.

Disclosure: Dr. Dryden reports no conflicts of interest.

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