Deep fixation sutures of the platysmaa further development of the SMAS facelift.
Dr. Dr. Frank Muggenthaler
Facharzt für Mund-Kiefer-Gesichtschirurgie
Ästhetisch-Plastische Operationen
Dr. Dr. Frank Muggenthaler
Specialist in oral and maxillofacial surgery
Aesthetic plastic surgery
SMAS facelift
Multi-layer facelifts, in which the SMAS is specifically lifted and tightened, enable a particularly harmonious and lasting rejuvenation of the contours of the face and neck. The way in which the platysma is displaced plays a key role here. The placement of additional fixation sutures under the platysma muscle presented here leads to further optimization of the neck contours. In addition, this technique enables the targeted lifting of sunken hypertrophic submandibular glands and reduces the risk of typical complications of a neck lift.
Patient voices
SMAS Facelift – The advantages
Pure skin lifts allow a very limited reduction of sagging areas of the face and have practically no lifting effect on the neck. On the other hand, they carry the risk of unnatural-looking distortions and unattractive scarring due to the increased skin tension.
Facelifts, in which the tissue between the facial skin and the deep facial fascia is mobilized and lifted separately, reduce these risks. The so-called Superficial Musculo Aponeurotic System (SMAS) anatomically essentially comprises the platysma muscle and the capsule of the parotid gland. If the capsule of the parotid gland is integrated into the SMAS, this facilitates the preparation of a stable flap due to the better anatomical clarity, which merges continuously into the platysma and can thus also make a decisive contribution to improving the neck contour when it is displaced and tightened. However, this is only possible if the SMAS and platysma are prepared far enough forwards and downwards, or if the retaining ligaments over the zygomatic bone and the front edge of the masseter muscle are loosened.
Thanks to the shifting and tightening of the SMAS, the tightening forces during a lift are limited to the depths, while the facial skin remains virtually tension-free. This considerably reduces the risk of unsightly distortions and conspicuous scars.
It is very common to gather the deeper tissue layer using plication or shirring sutures without first having mobilized the SMAS separately. This can also achieve a certain lifting of the SMAS and tightening of the platysma. However, the contouring options in the cheek area and under the jaw angle are limited. Plication seams also appear to be inferior to the SMAS technique in terms of durability.
Additional fixation sutures under the platysma
In the classic relocation and fixation of the SMAS, fixation sutures are only applied to the flap edges in the cheek area and under the ear. This can result in the following disadvantages: The spreading of the SMAS/platysma and tent-like tightening over the large head-turning muscle (sternocleidomastoid muscle) leads to an increase in tissue and discrete widening of the neck, which can be aesthetically displeasing. For the same reason, the prominent depression at the anterior border of this muscle is superimposed by the flap, which compromises the clear definition of the angle of the jaw.
A further problem can be post-operative bleeding, which can develop to a considerable size under the mobilized SMAS/platysma flap and then require surgical revision.
Since fall 2007, we have regularly placed four to five additional 4/0 fixation sutures (non-absorbable, braided polyester thread), which extend from the anterior edge of the sternocleidomastoid muscle forward to the underside of the platysma. This results in various advantages:
The anterior border of the sternocleidomastoid muscle and the parts of the platysma and subcutaneous fatty tissue located above it are moved a little forward, resulting in an aesthetically pleasing narrowing of the neck contour.
The dead space under the platysma and the SMAS is considerably reduced. This also reduces the risk of post-operative bleeding requiring revision.
The additional fixation sutures enable even better tightening of the platysma and contouring of the neck profile than is already possible with the conventional SMAS technique.
Lifting of enlarged sunken submandibular glands
Enlarged, sunken submandibular glands not only impair the esthetic appearance of a neck, but can also be associated with functional problems. In the past, very different treatment methods have been described to achieve a corresponding correction. Complete removal of the glands via a percutaneous submandibular approach can leave a noticeable scar and carries the risk of damage to the facial nerve. This treatment option is therefore only justifiable if the entire gland needs to be removed urgently. Partial resections of the gland are also possible via an incision under the chin, although visibility is limited and safe hemostasis may be difficult.
Suspension threads have also been described that wrap around and lift the glands from the inner periosteum of the lower jaw in order to merely lift glands that are too low.
As part of an SMAS lift, it is possible to partially or completely expose the submandibular gland by wide mobilization of the platysma. This allows a clear situation to be created so that the gland can be safely reduced in size or removed completely. The subplatysmal fixation sutures described above are ideal for moving sunken, slightly enlarged glands into a functionally and esthetically optimal position. The platysma can be tightened with great precision to give the glands the necessary support and cause the glands to lift.
Graphic 1: Illustration of the extent of the skin dissection (dark dashed line, the extent of the SMAS/platysma preparation (yellow dashed line), the stress vectors as a result of the deep suspension sutures (red arrows) and the displacement of the SMAS upwards and backwards (blue arrows). Graphics 2 and 3: Sequence of fixation sutures: The first suture lifts the SMAS, approximately at the level of the zygomatic arch. The following sutures successively bring the platysma under tension and reduce the dead space under the SMAS and platysma. Figure 4: The projection of the SMAS/platysmal flap is then pivoted under the ear and also fixed there.
Summary
Additional fixation seams on the undersides of the platysma and SMAS enable even better contouring of the neck. By reducing the dead space below the SMAS and platysma, this measure reduces the risk of serious secondary bleeding. Using these sutures, it is also possible to lift sagging, enlarged submandibular glands in a comparatively simple way.
