The SMAS is a sheet of tissue that envelops the face. It is attached to the deep tissues in many places around the face and attaches to the superficial tissues wherever the skin folds during facial animation. In my experience, the best way to get a great, long-lasting result is by lifting the SMAS and separating it from the underlying attachments. If you do not release these attachments, then the SMAS moves very little and the results are not as satisfying.
Plication does not allow for the release of the underlying attachments.
I stopped doing SMAS dissection, excision and imbrication 20 years ago because the SMAS is so thin and most patients it simply tears after excision and imbrication. In my experience the plication of the SMAS works very well and the benefit is that the SMAS correction holds. The skin flap mobilization works perfectly well after this technique and because the distal attachments are still in place and male better than totally mobilizing the skin flap in my opinion.
In our practice, we perform imbrication in the majority of facelifts. On a rare occasion on a multiple revisional facelift, we may use plication sutures instead. Imbrication tends to give a better and longer lasting result than plication. Tightening the SMAS is only one component of the face lift. Also look to see how the fatty deposits are are removed in the neck and the neck muscles are tightened. For many examples of imbricating facelifts, please see the link below.
There are many different techniques for performing a facelift. The most important factor in choosing a surgeon is finding one who has tried and true results with whichever technique he or she is the most experienced with. In my experience, I get the best results using an imbrication technique.
SMAS mobilization is a result of a technique that loosens and frees up this layer to achieve repositioning of the muscles of the face. The amount of mobilization depends on how much your surgeon frees up this layer. Just because you have part of the SMAS remove does not mean you get more mobilization and a longer-lasting result.
Earl Stephenson, Jr, MD, DDS, FACS
I personally would answer neither, because I think those approaches do not include a significant SMAS elevation and mobilization, and therefore are inherently limited in their ability to achieve skin flap mobilization. In general these approaches are used because they take less time as they require less dissection and potentially have less risk. I believe that a SMAS approach which involves thorough elevation, mobilization, and repositioning of the SMAS results in better correction of the mid-face/lid cheek junction with more complete and longer lasting results. However, there are no good long term studies which definitively show that a more extended SMAS elevation and mobilization technique results in better long term results.
One complaint that I have with any technique the involves cutting out a section of the SMAS is that you are throwing away precious tissue, mostly fat, which is extremely important in maintaining a natural youthful appearance. We all know now that facial aging involves a significant amount of loss of facial volume over time in addition to sagging or descent of the facial tissues. This why SMAS mobilization alone is not sufficient to achieve a comprehensive facial rejuvenation. I incorporate autologous fat grafting into every facelift procedure done today because it results in a more complete, softer, natural rejuvenation. Use of autologous fat has not been in widespread use for long enough to draw any conclusions about whether it helps provide a longer lasting result, but I think it is an essential component to almost any facial rejuvenation procedure done today.
There are many derivations of the use/treatment of the SMAS during a facelift. SMAS elevation with mobilization, imbrication or plication. All of these approaches have their place in facelifts, both in first time patients and secondaries. There are a number of factors which will allow choosing one approach over another including, overlying skin quality, soft tissue fullness/deficiency, primary or secondary cases with/without prior SMAS lift, SMAS mobility etc. Each case much be evaluated individually.
There are many different ways to lift the soft tissues of the face and SMAS imbrication, plication, and elevation all can do it a bit differently.