In a SMAS facelift, what's the difference between plication, imbrication and suspension?

Question

Which is the best technique for longevity and effectiveness in lifting jowls? From what I've read, suspension is used in MACS-type lifts and involves a loop-like suture, plication involves folding the SMAS in on itself (and can lead to bumpiness?) and imbrication seem a bit more technical and involved. Are there any other techniques besides these? What is the gold standard?

Kevin Sadati, DO · Answer

There are several different types of facelift techniques that are currently performed by facelift surgeons. The most important factor is that the technique that is used by a facial surgeon will create a youthful, natural with long lasting result. An ideal facelift result includes in part not having anyone assume you have had a face lift procedure. I think a patient that desires improved appearance but wants a natural, non-operated result will have to communicate this to his or her prospective surgeon but also seek out an experienced facelift surgeon that prefers to achieve these types of results. Experience is the key in facial rejuvenation. Vectors of facial tightening vary from patient to patient. For a 45- 50-year-old patient, I would not apply the same vector and tension that I normally apply to a 70-year-old face. In addition, direction of vectors must be modified during secondary or tertiary facelift to avoid artificial look. I have performed well over 3,500 face and neck lifts and published a specific technique that describe the rotational angles and amount of tension that must be applied during SMAS plication to avoid over or under tightening. A well-performed neck lift during facial rejuvenation is the paramount in a youthful-appearing face. I apply gradual tension on my SMAS as follow: starting at temple area there is only 20-30% tension on muscle plication, once at the jawlines the muscle is tightened 100%. This prevent pulled looked at the corner of mouth. In neck area the muscle must be tighten with greater tension than 100%, depending on the neck laxity. Look at the doctor’s before and after pictures, a talented and experienced facelift surgeon will have a smooth and well-contoured neck that enhances the facelift results. The face ages through a combination of changes including volume loss, skin changes, and soft tissue drooping. When facial rejuvenation is desired all of these changes must be addressed. Therefore, fat grafting, a facelift, and skin resurfacing frequently must be combined to accomplish a natural result.

Alejandro J. Quiroz, MD · Answer

Thank you for your question. When you perform any of the techniques that involved the deep plane is great the main difference is no the technique use the technician that execute the procedure. To have experience in the procedure is the key. For longevity the factor that is crucial is the quality of the skin you have and the care after the surgery.

Francis R. Palmer, III, MD (retired) · Answer

Hi, this is a great question.  The best way to answer this question is to have you think of the facial tissues in layers from the inside out:  The bone, the muscles that move the face/nerves that operate those muscles, the SMAS muscle layer, the subcutaneous fat layer and finally the skin.  Facelifts are by nature designed to tighten and remove excess skin.  In the 1980's it became standard that the SMAS muscle layer was also lifted as it was shown to not only improve the aesthetic appearance following a facelift but add longevity to the results.  Over the years there have been numerous methods of addressing the SMAS, with "imbrication" being the "gold standard" and most effective.  Imbrication means the SMAS layer is dissected, lifted, trimmed and re-sutured back together in the elevated position.  Plication means the SMAS is not dissected, lifted or trimmed but is "folded" upon itself. While this method is faster and easier for the facelift surgeon it's not accepted as effective as SMAS imbrication.  Finally, even less effective are suspension SMAS techniques using sutures or threads.
 Modification and shaping the face then should address the fat layer and the skeletal structure to create either a soft, feminine heart shaped face in women or a chiseled, angular handsome face in men.  Liposuction is a tried and true method of reducing subcutaneous fat in the face which I have used for over 30 years.  Dissecting the fat, by itself, would just split the fat layer into an upper and lower layer and would not remove or shape the fat and face. The reality is, there are many different ways to perform a facelift from incision length, incision placement, level of tissue dissection (skin only, SMAS, Deep Plane, Subperiosteal), different degrees of tissue undermining, how to lift and support (imbrication versus plication of the SMAS layer), how much excess skin to trim, is excess fat going to be reduced and finally will the overall shape of the face be made more feminine or masculine (while avoiding the over pulled, windswept appearance).  
 In my humble opinion however, there are some basic requirements that must be met in order for a facelift to be "effective", yielding "aesthetic pleasing" and "naturally attractive" results.  These include: 
 1. Some type of incision either curved around the front (preferred) or straight in front of the ear.  This is how excess skin is removed which is not possible with an incision behind the ear alone.  If you have so little excess skin on the face that "none" needs to be removed you are not a candidate for a facelift in the first place.
2. The facelift must address correction and softening of the "jowls" using a long lasting and effective technique.  If you have "jowls” these are sagging facial tissues and the main indication for some form of a SMAS facelift.  The underlying SMAS layer, of the face, must be dissected, lifted, trimmed and re-sutured (not merely folded or suspended with threads or sutures that will not last).  The excess skin is then removed and the facelift incisions closed.
3. Facial shaping must be combined to properly shape the cheeks, chin, jaw line and lips for feminizing or masculinizing the face as the case may be. I have performed many SMAS facelifts for over 30 years and have performed many minimally, invasive SMAS facelifts using the SMAS Imbrication technique.  Non smiling photos of your face from the front and side would help in the evaluation.  
 If you have "jowls”, in the lower face, these are sagging facial tissues and the main indication for some form of a SMAS facelift.  The underlying SMAS layer, of the face, must be dissected, lifted, trimmed and re-sutured (not merely folded or suspended with threads or sutures that will not last).  The excess skin is then removed and the facelift incisions closed.
 My most popular SMAS facelift is the minimally invasive, short incision SMAS facelift that has all the benefits of more invasive facelifts (traditional, mid-face, deep plane, cheek lift and subperiosteal facelifts) but with these added benefits:
very small incisions and no incisions extend or are placed within the hair.
minimal tissue dissection = less bruising and swelling = rapid recovery ( several days instead of weeks or months with the more invasive type facelifts mentioned)
can be performed in 90 minutes or less, with or without general anesthesiaproper SMAS Imbrication technique
no incisions within the hair = no hair loss
excess fat can be removed from the face and neck
excess skin removed from the face and neck
cheeks, chin and jaw line can be augmented with dermal fillers (I prefer Restylane Lyft) or facial implants
most patients fly back home to parts all over the world in as little as 3 days post-op
 I combine facial shaping with every facelift procedure.  When jowls are present, these should be done in concert and not alone or separately in order to create a naturally, more attractive face.  Following my beauty principles, women look the most feminine, youthful and attractive with heart shaped faces.  Heart shaped faces have cheeks that are full and round in the front.  Cheek augmentation with a dermal filler or using cheek implants for a permanent enhancement will create full, round cheeks that will feminize the entire face.
 A weak chin creates an imbalance making the nose appear larger, the mid face top heavy and the lower face look short that de-emphasizes the lips and allows early formation of a double chin.  Chin augmentation using a chin implant will add projection to the chin creating harmony and balance to the lower face.  I have found placement of a silastic chin implant, through a small curved incision under the chin (also allows excess skin removal) to be very safe, quick and highly effective.
Hope this helps.

In a SMAS facelift, what's the difference between plication, imbrication and suspension?

Answers (3)

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