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Asian Facial Rejuvenation by Extended SMAS Facelift Technique

Lee, Joo Heon, MD

Plastic and Reconstructive Surgery – Global Open: February 2017 - Volume 5 - Issue 2 - p e1244
doi: 10.1097/GOX.0000000000001244

From the April 31 Plastic Surgery Clinic, Seoul, Korea.

Received for publication October 31, 2016; accepted January 4, 2017.

Disclosure: The author has no financial interest to declare in relation to the content of this article. The Article Processing Charge was paid for by the author.

Supplemental digital content is available for this article. Clickable URL citations appear in the text.

Joo Heon Lee, MD, April 31 Plastic Surgery Clinic, 6th floor, Geonwoo B/D, Gangnam-daero 548, Kangnam-gu, Seoul 135-010, Korea, E-mail:

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

Asian faces have somewhat different characteristics that could be distinguished from those of the faces of whites in terms of both shape of the skull and facial fat. Asians usually have wide and flat faces with wide bizygomatic distance and underdeveloped premaxilla. Their facial fat is abundant around the malar and submalar regions. As the facial fat descends with aging, the Asian faces tend to be of a more rectangular and boxy shape. Along with facial tightening, more anatomically vertical, rather than oblique, repositioning of the descending facial fat is necessary to obtain more attractive angular facial shape in a rectangular face.1,2 As the malar is highlighted in a higher position with the improvement of submalar fullness and the jaw line is clearly defined by vertical repositioning of the facial fat, the facial shape can be more attractive and angular.3 We have done the extended superficial musculoaponeurotic system (SMAS) facelift technique4 with modification of the design of malar SMAS to regain attractive malar highlight without the widening of bizygomatic distance in Asian faces.

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  1. The retrotragal skin incision line and the area of skin undermining are designed.
  2. The subcutaneous flap is dissected.
  3. The malar, horizontal, and vertical SMAS flaps are designed.
  4. The malar SMAS flap is dissected from the underlying orbicularis oculi and zygomaticus minor muscle.

For steps 1–4, see video, Supplemental Digital Content 1, which displays the design of skin incision, subcutaneous undermining, design of SMAS, and malar SMAS dissection,

Video Graphic 1.

Video Graphic 1.

  • 5. The preauricular SMAS flap is dissected from the underlying sub-SMAS fat to the anterior border of the masseter muscle.

For step 5, see video, Supplemental Digital Content 2, which displays the sub-SMAS dissection in the preauricular region, preparotid region, area of lateral to masseter muscle, and around the sternocleidomastoid muscle

Video Graphic 2.

Video Graphic 2.

  • 6. The major retaining ligaments (zygomatic, upper, and mid masseteric ligaments) are released.

For step 6, see video, Supplemental Digital Content 3, which displays the release of the major retaining ligaments and deep fascia covering the buccal fat pad in sub-SMAS dissection,

Video Graphic 3.

Video Graphic 3.

  • 7. The dissected SMAS flap is vertically repositioned and fixed by the 3-0 Mersilene suture.

For step 7, see video, Supplemental Digital Content 4, which displays the vertical repositioning and suture fixation of the SMAS flap,

Video Graphic 4.

Video Graphic 4.

  • 8. The skin flap is advanced horizontally without tension.
  • 9. A suction drain is inserted.
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  1. To reposition the malar fat to a higher position in wide bizygomatic patients, the malar SMAS flap is designed more laterally and cephalically (video 1).
  2. The preauricular vertical SMAS flap is designed below 4 cm from the mandibular border (video 1).
  3. The SMAS flap is dissected from the underlying sub-SMAS fat and subplatysmal fat, which covers the parotid masseteric fascia and the origin of zygomaticus major muscle (video 2).
  4. The lower platysma-SMAS flap is dissected from the fascia of the SCM muscle medially 3–4 cm to the area of loose attachment between the platysma muscle and the deep fascia5 (video 2).
  5. The upper and mid masseteric ligament is released from the undersurface of the SMAS flap, and the anterior masseteric ligaments are usually not released (video 3).
  6. The platysma-SMAS flap below the mandibular angle is sutured first upward to the level of the arch of zygoma. The malar and medial SMAS flaps can be vertically repositioned in turn as well (video 4).
  7. The SMAS flap is folded and sutured tightly (video 4).
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Light compressive dressing is applied, and suction drain is removed on postoperative day 3.

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1. Pessa JE. An algorithm of facial aging: verification of Lambros’s theory by three-dimensional stereolithography, with reference to the pathogenesis of midfacial aging, scleral show, and the lateral suborbital trough deformity. Plast Reconstr Surg. 2000;106:479–88; discussion 489.
2. Owsley JQ, Roberts CL. Some anatomical observations on midface aging and long-term results of surgical treatment. Plast Reconstr Surg. 2008;121:258–268.
3. Stuzin JM. Restoring facial shape in face lifting: the role of skeletal support in facial analysis and midface soft-tissue repositioning. Plast Reconstr Surg. 2007;119:362–76; discussion 377.
4. Stuzin JM, Baker TJ, Gordon HL, et al. Extended SMAS dissection as an approach to midface rejuvenation. Clin Plast Surg. 1995;22:295–311.
5. Stuzin JM, Baker TJ, Gordon HL. The relationship of the superficial and deep facial fascias: relevance to rhytidectomy and aging. Plast Reconstr Surg. 1992;89:441–9; discussion 450.

Supplemental Digital Content

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Copyright © 2017 The Author. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.