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Unilateral Superficial Musculoaponeurotic System Plication in Facial Reconstructive Surgery

Wanitphakdeedecha, Rungsima M.D., M.A., M.Sc.; Nguyen, Tri H. M.D.; Chen, T Minsue M.D.

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Plastic and Reconstructive Surgery: January 2009 - Volume 123 - Issue 1 - p 18e-19e
doi: 10.1097/PRS.0b013e318194d257
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The superficial musculoaponeurotic system (SMAS) was first described by Mitz and Peyronie in 1976.1 It is a fundamental anatomic structure that serves as a reference for tissue undermining and structure for plication in rhytidoplasty, rejuvenation, and reconstruction.2

The SMAS may be plicated for several reasons, including rejuvenation of the aging face via rhytidectomy, facial paralysis and palsy, as well as facial reconstructive surgery. These techniques can produce long-lasting results. In the setting of facial reconstructive surgery, the benefits of SMAS plication include decreasing both wound edge tension and wound defect size.3 SMAS plication shifts the majority of the wound closure tension from the dermal–subcutaneous junction to the fascia below. By minimizing the wound edge tension, scar appearance is optimized. Moreover, by reducing the wound defect size, less complex reconstructive options can be considered.

In this article, we discuss the anatomy of the SMAS and our experience with unilateral SMAS plication in the setting of facial reconstructive surgery to reduce both wound edge tension and wound defect size.

SMAS plication adds a minimal amount of time (approximately 5 minutes) to a standard wound closure. The additional cost is simply that of two to three sutures. If the wound is under significant tension and tissue restraint, undermine in the tissue plane superficial to the SMAS to avoid injury to the neurovascular structures below. Plicate the SMAS by placing the suture at the leading edges of the surgical defect. Either absorbable or nonabsorbable sutures may be used. To minimize facial distortion, especially that of adjacent free margins, the vector of plication should be selected carefully. To maintain the lift, it may be necessary to use nonabsorbable sutures and/or to anchor the tissue to the periosteum or the deep temporal fascia. Patients should be instructed to avoid forcible movement of the skin, which may remain tight for as long as 3 weeks. In addition, patients should be reassured that the asymmetry resolves over the next several months with excellent aesthetic outcomes.

Between June of 2006 and July of 2007, a total of 30 patients underwent unilateral SMAS plication after Mohs micrographic surgery. Of these, 77 percent (23 of 30 patients) were men and 23 percent (seven of 30) were women. The average age was 63.9 years (range, 36 to 84 years). The wound characteristics (defect location, size, and closures) are described in Table 1. The average defect area was 3.83 cm2 (range, 0.63 to 11.02 cm2). Average follow-up was 9.67 months (range, 1 to 15 months).

Table 1
Table 1:
Wound Characteristics and Closures

Fifty percent of closures (15 of 30 closures) were linear; the remaining 50 percent were adjacent tissue rearrangement. There were no hematomas or infections. Some patients noted subtle tightening, lasting from 1 week to 2 months. Only a few patients noted mild facial asymmetry in the early postoperative course, and in all cases, the asymmetry resolved 2 to 3 months postoperatively. All patients were satisfied with the cosmetic results (Fig. 1).

Fig. 1.
Fig. 1.:
(Above) Immediate postoperative appearance. (Below) Three-week postoperative appearance.

Unilateral SMAS plication before suturing of the overlying tissue provides excellent functional and cosmetic results. By reducing wound tension and wound size, repairs are often less complex than anticipated.

Rungsima Wanitphakdeedecha, M.D., M.A., M.Sc.

Department of Dermatology

Faculty of Medicine Siriraj Hospital

Mahidol University

Bangkok, Thailand

Tri H. Nguyen, M.D.

T. Minsue Chen, M.D.

Department of Dermatology

University of Texas M. D. Anderson Cancer Center

Houston, Texas


1. Mitz V, Peyronie M. The superficial musculoaponeurotic system (SMAS) in the parotid and cheek area. Plast Reconstr Surg. 1976;58:80–88.
2. Anderson KW, Baker SR. Advances in facial rejuvenation surgery. Curr Opin Otolaryngol Head Neck Surg. 2003;11:256–260.
3. Pomaranski MR, Krull EA, Balle MR. Use of the Z-plasty technique for forehead defects. Dermatol Surg. 2005;31:1720–1723.

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