The extended superficial musculoaponeurotic system (SMAS) lift avoids high levels of tension and creates results superior to those of conventional SMAS lifts in properly selected patients, says the extended SMAS lift's co-developer.
James Stuzin, M.D., a Coconut Grove, Fla., surgeon in private practice, says he began devising the procedure in 1989 with a colleague, Miami plastic surgeon Thomas Baker, M.D.
"We believed that the standard lateral SMAS procedure wasn't doing what we wanted to do — we wanted to get away from more skin-tension facelifts. By extending the SMAS more anteriorly, we believed we could get better postoperative contour correction. And that's been true in our experience (Stuzin JM, Baker TJ, Gordon HL, Baker TM. Clin Plast Surg. 1995;22(2):295-311)," Dr. Stuzin says.TAKING SHAPE Dr. Stuzin says he and Dr. Baker hit upon the idea for the extended SMAS lift somewhat serendipitously while contemplating the traditional lateral SMAS dissection first described in 1976 (Mitz V, Peyronie M. Plast Reconstr Surg. 1976;58(1):80-88). "We believed that if we extended it high up into the malar area, we could elevate the malar pad," he says. "And when we pulled on the malar pad, we could flatten the nasolabial fold."
However, he says that as he continued to research the procedure through cadaver work, "I realized that this incision design, from an anatomic viewpoint, was very useful because it allows you to free the superficial fascia from the restraint of the retaining ligaments," namely the carotid, zygomatic and masseteric ligaments. "Once you got into the mobile area of the SMAS, it moved more freely," with virtually no increase in tension.
Similarly, Dr. Stuzin says facial aging studies showed that the extended SMAS lift's incision design is also very useful aesthetically. It allows repositioning of descending anteriorly based facial fat back up into the lateral midface, where it resides during youth, he explains.
Another key to the procedure is Dr. Stuzin's commitment to two-layer SMAS facelifts including formal SMAS dissection. "We now have many alternatives to this procedure, such as plication techniques or SMAS-ectomies," he says. "But at least in my hands, when I mobilize the superficial fascia and get the SMAS free from the restraint of the retaining ligaments, I have greater aesthetic versatility and control. It seems intuitive to me that once you get this layer up, you can vector it anyway you want to," thereby achieving more patient-specific results. "I have more control in terms of keeping the fat where I want it postoperatively."
Over the years, Dr. Stuzin says he has made modifications to the procedure that have allowed him to further titrate it according to individual patients' needs and to achieve more consistent results. "I have a better feel for what this procedure does, as well as what it doesn't do," he says.
VALUE IN VARIABILITY Biomechanically, Dr. Stuzin says, the extended SMAS lift allows one to vary the SMAS' release, its vector and how one chooses to fix it (Mendelson BC. Plast Reconstr Surg. 2001;107(6):1545-1552; discussion 1553-1555, 1556-1557, 1558-1561). These variables will determine the resulting contour, he says.
"I still believe you must free the SMAS from the restraint of the retaining ligaments so that it moves freely, or you will lose contour. But when I first started doing the operation, because I was so focused on anatomy, I used to overdissect the SMAS, taking down basically all the retaining ligaments. And that isn't necessary," he says. Instead, surgeons need merely to access the mobile area of the SMAS, "So that when you pull on it, it gives you the traction effect you're looking for. Therefore, at this point, I tend to dissect the SMAS less than I used to."
Dr. Stuzin says he dissects through the fibrous and somewhat difficult area of the restraining ligaments. "Then suddenly, the SMAS will free up, and the dissection becomes easy," he says. "When this happens, I know I'm into the mobile area of the SMAS. I'll pull on it" to make sure before stopping the dissection.
Limiting the SMAS dissection reduces the procedure's morbidity and improves its precision, Dr. Stuzin says. Additionally, "Patients tend to look a little less 'surgical.' If you overdissect, there's a tendency toward more of a surgical stigma in the results."