In a composite facelift The skin remains attached to the SMAS and is carried with it as the SMAS is repositioned and secured. This improves blood supply to the skin and allows for a tension free closure of the skin. The more conventional facelift separates the skin from the SMAS where they are dealt with independently.
Your question is a great one and you will certainly find lots of different opinions but the true difference between a SMAS facelift and a composite facelift is actually the number of planes of dissection. Simply put in any "SMAS" approach the skin flap is undermined as a separate entity from the superficial surface of the SMAS. A true SMAS flap facelift then completes a full dissection underneath the SMAS to mobilize and support it. Thus a SMAS facelift has two separate flaps and two complete plains of dissection. There are of course variations of this such as "SMASectomy" and SMAS plication. In my opinion of the SMAS techniques the extended full SMAS flap is superior as it affords excellent control of vectors and natural redraping. Early in my career I trained with James Stuzin who is an advocate of extended SMAS facelifts and had wonderful results with this technique. My technique evolved however to selected dissection and towards more of a composite technique for several important reasons and I believe my results and recovery period is vastly superior to my previous results. A composite facelift means that for the most part the SMAS and skin are a composite unit transposed together. This makes a lot of sense- instead of devascularizing both the skin and SMAS weakening them and relying on scar planes to hold them together, a composite facelift harnesses the power of ligamentous zones of adhesion to support the lift. In the composite lift that I employ, subcutaneous dissection is very limited and the SMAS is opened in the mobile space over the masseter muscle. at this point a potential space called the premasseteric space is entered and developed. The roof of this space is freed and the branches of the facial nerve are left on the floor. Some surgeons are not comfortable with this proximity but personally I feel it is the safest as the anatomy is clearly visible in general. Once the space is developed the composite unit of healthy well vascularized skin and SMAS is elevated and repositioned and secured to the fixed SMAS closer to the ear creating a new ligament between sturdy tissues with excellent blood supply. Because the complosite unit is moved back together, there is almost zero dead space and very low risk of hematoma. I have found that I can get a more dramatic natural appearing rejuvenation with less swelling and recovery doing things this way. Another advantage is that unlike the full SMAS technique where there is always some degree of tension on the skin flaps(although most is supported by SMAS) the composite flap is secured so close to the suture line that skin closure can be truly zero tension and the scars are almost imperceptible in days. Keep in mind that every surgeon has different variations in the way they address these issues and may use the words composite to describe something different. Although I am now a huge proponent of the composite technique with my personal modifications, there are good and bad results with all techniques and the most important aspect of your decision is the surgeon that you choose. There's more than one way to skin a cat! I hope this helps!all the best,Rian A. Maercks M.D.
