COSMETIC Suture Suspension Malarplasty with SMAS Plication and Modified SMASectomy: A Simplified Approach to Midface Lifting R. Barrett Noone, M.D. Background: The elements of midfacial aging include elongation of the lower Philadelphia and Bryn Mawr, Pa. eyelid, flattening of the malar eminence, hollowing in the submalar area, laxity of the jowls, and deepening of the nasolabial crease. Attention to rejuvenation of these areas has included various techniques involving movement of the superficial musculoaponeurotic system (SMAS) and elevation of the malar fat pad. A trend toward simplification in midface lifting has introduced the use of suspension sutures. Methods: This paper describes an approach to midfacial rejuvenation that combines the elements of SMAS plication and lateral SMASectomy with a suture suspension of the malar fat pad to achieve long-lasting improvement of the aging midface. The ptotic malar fat pad is suspended by suture to the deep temporal fascia. The suture passes from the subcutaneous position where it is fixed to the malar fat pad, through the SMAS, and over the periosteum of the zygoma, and is fixed to the deep temporal fascia. Plication of the SMAS over the suture, combined with lateral SMASectomy, provides three vectors of elevation beneath the skin in midface rhytidectomy. Results: This technique was used in 259 patients between October of 2000 and October of 2004, producing effective long-lasting results with limited convales- cence and minimal complication rates. Conclusions: Safe dissection in the subcutaneous plane avoids injury to facial nerve branches. Plication of the SMAS with suture suspension of the malar fat pad avoids the prolonged convalescence and other morbidities of extensive sub-SMAS or deep plane dissections. This simplified approach can be quickly and easily performed under local anesthesia as an isolated midface procedure, or can be combined with surgery of the forehead, eyebrows, eyelids, or neck by standard techniques of rejuvenation. (Plast. Reconstr. Surg. 117: 792, 2006.) he effects of the aging process on the soft supplemented external incision, skin-tightening tissues of the midface include elongation of rhytidectomies with direct procedures involving Tthe lower eyelid, flattening of the malar the SMAS. These range from simple plication to eminence, volumetric loss in the submalar area extensive composite rhytidectomies. Variations of the cheek, prominence of the jowls, and deep- in SMAS techniques have resulted in substantial ening of the nasolabial fold. Since the descrip- long-term correction of the above elements, with tion of the superficial musculoaponeurotic sys- the exception of the nasolabial crease. Recogni- tem (SMAS) by Mitz and Peyronie in 1976,1 tion of the malar fat pad as an entity distinct surgical solutions for facial rejuvenation have from the SMAS and intimately involved with the aging process at the nasolabial fold led to an evolution of techniques involving repositioning From the University of Pennsylvania School of Medicine, and the Division of Plastic Surgery, Main Line Health Hospitals. of the malar fat pad in combination with SMAS Received for publication February 5, 2005; revised June 14, procedures. Although they produce excellent re- 2005. sults, many of these techniques require extensive Presented at the 73rd Annual Meeting of the American dissection and have the potential for increased Society of Plastic Surgeons, Philadelphia, Pa., October 10, morbidity and prolonged convalescence. The 2004. search for less extensive solutions to the problem Copyright ©2006 by the American Society of Plastic Surgeons has introduced the concept of suspension su- DOI: 10.1097/01.prs.0000209373.95115.70 tures in various forms for facial rejuvenation. 792 www.plasreconsurg.org Volume 117, Number 3 • Suture Suspension Malarplasty This article describes a simplified approach to poral branch is well posterior to the point of pen- midface rhytidectomy that combines suture sus- etration of the SMAS by the suture retriever. The pension of the malar fat pad with SMAS plication zygomatic branches are inferior and anterior to and limited lateral SMASectomy. This technique this point, described by Mendelson as a surgical was used in 259 patients in the 4-year period “safe space.”5 between October of 2000 and October of 2004. DESCRIPTION OF TECHNIQUE APPLIED ANATOMY Suture suspension malarplasty with SMAS pli- In the midface, the SMAS is a fascial layer cation may be performed as an isolated midface separating the subcutaneous fat from the fascia lift procedure, or can be combined with other enveloping the parotid gland, the mimetic mus- facial rejuvenative operations, including blepha- cles, and facial nerve branches. The SMAS is an roplasty, brow lifting (open or endoscopic), and extension of the superficial cervical fascia into the any procedure performed for rejuvenation of the face and is continuous with the temporoparietal neck. The location of incision depends on the fascia in the temporal region. The SMAS is thickest extent of the operative procedure selected. The over the parotid region and becomes thin in its conventional incision enters the temporal area on anterior extent over the malar region. The malar a line corresponding to the posterior aspect of the fat pad, a triangular subcutaneous structure based external auditory canal. Alternatively, a skin inci- at the nasolabial fold with its apex at the malar sion may be made along the temporal hairline, but eminence, lies superficial to the SMAS in the an- the posterior aspect of such an incision must allow terior midface, and is considered part of the “fas- exposure to the deep temporal fascia. The incision cial-fatty” layer of the face.2 Ligaments from the extends in the conventional face lift location into periosteum of the zygoma run through the sub- the post auricular sulcus if only the midface is cutaneous portion of the malar pad and insert addressed. If exposure for neck surgery is desired, directly into the dermis. Thus, the malar pad pro- posterior extension over the mastoid extends vides fullness in the youthful midface. With aging, along a line directed posteriorly from the superior these fibrous septae relax, allowing ptosis of the aspect of the external auditory canal. The skin flap malar fat pad and deepening of the nasolabial is elevated in a subcutaneous plane to a point fold. Traction on the malar fat pad in a supero- consistent with a line drawn perpendicular from oblique direction, along a line from the midpor- the lateral canthus. The anterior extent of this tion of the nasolabial crease to the junction of the dissection is approximately 2 cm posterior to the zygoma and temporal bones, elevates the skin of oral commissure in the face. The integrity of the the medial cheek and flattens the nasolabial fold. adherence of the malar fat pad to the skin lateral An understanding of the anatomy of the tem- to the nasolabial fold is maintained. If neck sur- poral region is critical to this technique.3 The gery is combined, superficial dissection of the skin SMAS extension (the temporoparietal fascia) in- continues inferior to the border of the mandible vests the frontal (temporal) branch of the facial to reach the submental incision. The superior ex- nerve (cranial VII) and the branches of the su- tent of the subcutaneous dissection extends to just perficial temporal artery. This superficial fascia is below the orbital rim and over the superior border separated from the deep temporal fascia by loose of the zygoma. At this point, the subcutaneous areolar tissue. The deep temporal fascia covers the dissection is superficial to the superficial temporal temporalis muscle and splits to envelop the peri- fascia and caudal to the hair-bearing skin of the osteum of the zygomatic arch. As will be described, temple. The supra-auricular incision in the tem- the suture retriever is placed on the surface of the poral area is carried deep to the superficial fascia deep temporal fascia and is directed through the to identify the deep temporal fascia. Dissection is loose areolar tissue in the prezygomatic space4 continued in an anterior direction in this plane deep to the temporoparietal fascia and the tem- until the parietal branch of the superficial tem- poral nerve branch. poral artery is identified, suture ligated, and di- The temporal branch crosses the zygomatic vided. Thus, a deep plane is entered between the arch and innervates the frontalis, orbicularis oculi, superficial and deep temporal fascia. The extent and corrugator muscles. The zygomatic branches of flap dissection in the plane immediately above extend to the lateral angle of the orbit and also the deep temporal fascia is dependent on the ex- into the orbicularis oculi. The buccal branches are tent of temporal scalp resection desired. Only deep to the SMAS and are well away from any minimal deep dissection anterior to the division of maneuvers involved with the technique. The tem- the artery is needed for exposure for the suture 793 Plastic and Reconstructive Surgery • March 2006 retriever. After dissection is complete, the malar the anterior third of the zygomatic arch. At this fat pad is identified and elevated with the surgical point, it penetrates the SMAS through the surgical forceps along the line between the upper nasola- “safe space.” The end of the suture retriever is then bial fold and the midzygoma. An estimate is made in the subcutaneous position, with the handle at of the amount of movement of the malar fat pad the level of the deep temporal fascia (Fig. 1). The and the contiguous anterior SMAS. Measurements polydioxanone suture is passed through the wire indicate that the malar fat pad can be advanced loop of the suture retriever by way of the proximal between 1.0 and 2.5 cm. When the maximum ex- needle end and secondly by the distal free end of cursion is judged with the surgical forceps, a fig- the suture.