By Michael Sundine, MD

There has been a great deal of attention placed in the media recently on so-called “lunchtime face lifts.” These lifts are marketed extensively with the claims that they can be performed under local anesthesia only in a very short amount of time with minimal downtime and excellent long-lasting results. With all of these claims it begs the question of why it is better for the patient to undergo a SMAS-based face lift.

In order to accomplish a mini-face lift procedure under local anesthesia, the procedures mainly focus on elevation of a small area of the skin in the area around the ear and then place tension on that skin in order to improve the wrinkles. However, there are several problems with this approach.

Skin is biomechanically a very elastic material. Placing significant amounts of tension on facial skin has resulted in some fairly characteristic problems. When the tension on the skin has been used to try to reposition the facial fat back onto the cheek bones and to lift the jowls back into the cheek patients have received a characteristic wind-blown “face-lifted” appearance. The elasticity of the skin then pulls back away from the scars such that there is an early relapse of the facelift, widened scars, pixie ear deformities, retraction of the tragus, and there may be wound healing problems with skin necrosis because of the tension of the skin. Another problem with skin-only face lifts is that they tend to flatten the facial structures and lead to an unnatural appearance. The youthful face is not gaunt and tight but rather full and soft especially over the cheek bones.

Finally, the skin-only face lift procedures are very short lived because the skin support stretches and the soft tissues relapse. The only published study on the longevity of face lifting (by Sundine et al.) showed that with a high-SMAS face lift on average patients waited 12 years before needing another face lift. Clearly the SMAS contributes significantly to face lift longevity.

The SMAS (superficial musculoaponeurotic system) is a layer of tissue that is deep to the skin but superficial to the muscles of the face. The SMAS is a layer that is biomechanically very strong. Use of the SMAS allows for a suspension of the facial fat to restore the heart-shaped face of youth. Because of the strength of the SMAS the suspension of the facial fat is very strong. With the tension on the deep tissues the skin is able to be tailored with virtually no tension allowing for precise wound healing and fine invisible scars.

The SMAS also allows for the deep tissues (facial fat) to be suspended at a different vector than the skin. In the majority of face lift procedures the deep tissues need to be suspended in a more vertical direction, whereas the skin mostly needs to be re-draped in a more posterior direction. The SMAS can improve the softness over the cheekbones. It can flatten the upper and lower nasolabial fold and can lift the corner of the mouth. The use of the SMAS can also support the tissues under the chin with hammock support.

Thus the use of the SMAS allows for improved aesthetic results and a more natural youthful appearance by the elevation of facial fat and removal of skin without any tension and a resulting improvement in scarring.