Why would a Surgeon choose a SMAS-imbrication over a SMAS-ectomy, where is the logic in keeping excess SMAS in the face?

Question

Also, wouldn't it be counterproductive to dissect and re-suture SMAS to a face that is seeking to Lift a droopy jowl look? Just like the outer most layer excessive human skin is dissected and disposed of, why wouldn't you wanna dissect and disposed of excess SMAS?

Ronald J. Edelson, MD · Answer

The are many different things that surgeons perform to tighten the SMAS. I believe it is important to tighten the SMAS but there is no evidence that one procedure works better than another.

Steven H. Wiener, MD · Answer

This is a technical issue, that has divided plastic surgeons for many years.  Some surgeons prefer imbrication of the SMAS is a safer operation, and has long term excellent results.  Other plastic surgeons prefer elevating and excision of a strip of SMAS and then suturing the SMAS back together. This also has long term excellent results. The surgeons skill and experience will help determine the typw of facelift that is best for you.

Edwin F. Williams, III, MD · Answer

I agree with your stance. This is why I recommend the deep-place facelift for the majority of my patients, especially if they have extensive midface descent and jowling. The SMAS plication and imbrication techniques are more of a personal preference to the surgeon - both of which serve the purpose of tightening the SMAS, however the deep place facelift offers better and longer lasting results.

Evan Ransom, MD, FACS · Answer

Thank you for the great question. Without getting too technical, the treatment of the SMAS varies between facelift techniques. In an imbrication, the SMAS is overlapped and sewn at the lateral cheek. This gives the surgeon an opportunity to use the existing facial volume -- which has now been released and lifted -- to add volume to the upper face. Having more volume in the upper cheek and temple region is considered a sign of youth. In a SMAS-ectomy, the excess SMAS is removed. There are differences in where this takes place in the face, however. A clear discussion with your surgeon of his/her preferred method (and reasoning) would be appropriate. Best of luck moving forward!

Alejandro J. Quiroz, MD · Answer

Thank you for your question. In some occasions we use the volume of the SMAS to create more chick projection to the malar area. We have the option to use the option, but we don’t do it all the time.

George Volpe, MD · Answer

When undergoing a facelift, many undergo a two layer facelift with the deeper layer being the SMAS layer. There are several ways to help support the elevation of the skin by a tightening the SMAS. This could be excising a portion of it and placing internal sutures to approximate the two edges of the SMAS layer which helps elevate the SMAS. Another way is to imbricating the SMAS, that is placing sutures similar to the first example but without excising that portion of the SMAS and letting it fold over itself. There is a technique in which a longer sutures placed anchoring to the more secure SMAS tissue higher just in front of the year and looping a suture down along with the SMAS which is a type of elevation but with a better anchor point. And the fourth most common is to elevate that layer as a separate flap and to lift up the lower SMAS by advancing and excising redundant SMAS tissue. There is no good study to show that one method is better than the rest. It is true that as one folds over a SMAS versus removing SMAS there is more volume in the region where the SMAS flap is folded over itself. For some patients, this is beneficial as it introduces more volume in the higher layers of the cheek. For some patients, this is not noticeable. Many times it is surgeons preference or training that guide them into the use of one option versus the other. It would be good to question your surgeon regarding these small nuances to hear their opinion with regards to your face.

Ram Kalus, MD, FACS · Answer

Thank you for your question. The facial anatomy and the aging process are far more complex than simple sagging or excess. Facial aging includes the relaxation of tissues (which can result in lax skin and jowl formation), but also in the loss of volume, particularly in the mid face. Today's trends are not only to preserve as much tissue as possible, but to even augment that tissue with fat grafting at the same time. The term "baby fat" is not coincidental. Look at the faces of younger people and you will notice more roundness and fullness in general terms. In other words more fat in the face is actually a desirable feature when it comes to looking more youthful, and this is ironic since most of us are trying to reduce our total body fat everywhere else in our bodies. Discuss these questions with your selected board certified plastic surgeon or facial plastic surgeon, who can specifically advise you on your customized treatment plan to best meet your aesthetic goals. Best of luck to you.

Roger J. Friedman, MD · Answer

The issue is whether you need volume in your face. If you have a narrow face, possibly with cheek hollow you would do better with SMAS imbrication as this procedure adds volume to your face. If on the other hand you have a round face you do not need the additional bulk and would benefit by removal of the excess SMAS as a SMASectomy.

Johnson C. Lee, MD · Answer

Patients who tend to have hollowing of their face or loss of volume would be better off with a smas plication so that you maintain the restore the height and volume of the face which is associated with a youthful appearance. Some patients still have a good volume or thickness to their face in which case, a smasectomy may be better to prevent them from looking too "Full" in the face. Hope this helps!Johnson C. Lee, MD 
Board-Certified Plastic Surgeon

Patrick Flaharty, MD FAACS · Answer

A SMAS imbrication or plication can be a very effective procedure in thinner patients where we want to preserve tissue and a thorough plication is enough to lift and reshape the jawline and neckline. Patients with thicker, heavier tissue may require a SMASectomy which is more powerful in lifting the loose tissues of the lower face and neck. In these heavier, fuller faces removing excessive SMAS can assist in thinning and reshaping the face. Which technique to employ is decided based on the skin type, tissue thickness, facial fullness and the degree of laxity of the lower face and neck.

Why would a Surgeon choose a SMAS-imbrication over a SMAS-ectomy, where is the logic in keeping excess SMAS in the face?

Answers (15)

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