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Purse String formed Plication of the SMAS with
Fixation to the Zygomatic Bone

Purse String formed Plication of the SMAS with Fixation to the Zygomatic Bone.

Abstract:
The SMAS (Superficial Musculoaponeurotic system) surgery revolutionized facelift procedures. The idea of having one direction of traction with suturing and fixation of SMAS to a stable structure is gaining weight. Our contribution is the fixation of the SMAS and the ESP (Extention of the Supraplatysmal Plane)2 to the zygomatic bone periosteum and to achieve stable traction and fixation. We have achieved excellent stability of the SMAS and a perfect fullness of the cheeks with traction of the platysma by means of purse string formed collecting and suturing to the zygomatic bone which will end up giving a younger look to patients. This procedure has not been described before in medical literature.

This new suturing technique developed by the author (Figures 2, 3, 4 & 5) which suspends the SMAS, the extention of the platysma and the parotid fascia to the periosteum of the zygomatic bone at the lateral cheek where no nerve or vessels are present, achieves almost the same and sometimes even better results at the lower face and neck in younger patients. A modified purse-string formed plication (superficial with many small bites) of the SMAS and the parotid fascia plicated with two 2/0 Ethibond Sutures (Ethicon Co. Norderstedt, Germany) and fixed to the periosteum of the zygomatic bone gives a natural look to the lower face and a much better result to the neck. The Author2 calls these two sutures "U and "O" sutures. The "U-Suture" picks up the neck soft tissue and the extention of the platysma (ESP) whereas the "O-Suture collects and plicates the SMAS, Parotid fascia and the fat pad (Figure 2 and 3). It also fills the cheeks so that patients have a long lasting enlargement of the cheek bones which gives them a younger look.

Almost three decades ago Skoog3 demonstrated that dissection could be performed beneath a layer, later to become known as SMAS, and a new era in facelift surgery began. In 1977 Owsley5 reported plicating the SMAS tissue which gives an optimal traction of the lower facial tissues. During the following years different surgeons chose to use the SMAS in different ways, but typically a single large flap was elevated over the lower cheek. In the early 1980s Jost and Lamouche4 published articles on resection and even segmentation of the SMAS flaps pulling in different directions. Recently Baker7 published his work on "Short Scar Face lift" with lateral SMASectomy.

The author describes a technique which requires a modified superficial muscular aponeurotic (SMAS) plication in purse-string form2. At the same time the ESP6 will also be pulled together to achieve a better result of the neck. The soft tissue (the SMAS, parotid fascia and the extention of the platysma of the submandibular region) will be pulled together by means of a purse string formed suture with multiple small bites (in order to stay superficial) which will then be fixed to the periosteum of the zygomatic bone with a periost needle

The initial description of fixation of the SMAS and the parotid fascia to the periosteum of the zygomatic bone is based on the belief that two sling formed sutures sutured to the periosteum of the zygoma can suspend the lower facial tissues and the ESP6 (Extention of the Supraplatysmal Plane) would be the most appropriate solution to a lower face lift2. We strongly believe that more stabilization of the SMAS is required during a facelift in order to achieve better and longer lasting results. To ensure further stability of the lower face and to correct the neck, the extention of the platysmal muscle is also sutured and suspended and fixed to the zygoma.

Figure 1: The place of fixation for the sutures is the perisoteum of the zygomatic bone which is free from vessels and nerves.

The Technique
After the skin incision and coagulation of the bleeding vessels, the skin is raised and undermined below the subcutaneous fat tissue and above the SMAS. The Supra SMAS region and the parotid fascia layers will be seen. The suturing starts from the periosteum of the zygomatic bone approximately 3 to 5 cm away from the tragus. The surgeon has to feel the bone and if necessary, make a small incision and free the periosteum. This place is called "No Man's Land" (Figure 1). There are no vessels and nerves in this region. A major injury in trained hands is not possible. The SMAS plication is performed with two sutures of 2/0 Ethibond (Ethicon Co. Germany). The first suture ("U" suture) is vertically inserted between the level of zygoma and the ESP below the mandibular rim. This suture will pull the neck higher and tighten it. The second suture ("O" suture) is inserted with an angle of 45 degrees in order to pick up the fascia of the parotid gland and SMAS and pulls the lower face posteriorly and superiorly (Figure 2 and 3). Undermining more than 6 to 8 cm away from the tragus towards the midline is not needed. The author believes that less undermining will pull the soft tissue as a whole piece (en bloc) verticallly. The suturing is done in multiple small bites and superficially. The soft tissue is, thereby, pulled and tightened up like a purse string and sutured by a non-resorbable material at the periost of the zygomatic bone.
Fat should not be removed straight away from the jowls during dissection of the supra-SMAS plane. The jowl fat pads can be liposuctioned openly (vacuum cleaner technique). A better method is the fixation of the fat pad of the hanging cheeks to a higher position at the level of the cheeks which can be an advantage in most cases, giving the face a youthful and natural look. Hoefflin6 describes this procedure as "pulling on the SMAS is like repositioning a living room sofa by pulling on the carpet. It's easier to just pick up the sofa and position it where you want it". This procedure is called "Fat Repositioning".

Results:
In our study 250 patients have undergone this procedure. Twelve of the patients were male (4.8%) and the rest were female (95.2%). Only three cases (1.2%) of temporary facial nerve palsy (the temporal branch of the facial nerve which is medial to the arch of the zygomatic bone and can be injured if hidden in scar tissue) in patients with a secondary facelift have been observed, which disappeared shortly afterwards. Two patients (0.8%) developed hematomas, one of which had to be aspirated. There has been no case of skin necrosis or infection occurring. Forty four (17.6%) patients complained of feeling tension and pain in the pretragal area, however this went away after 3 weeks. A temporary (lasting 8 to 12 weeks) soft tissue dimpling beneath the ear lobe due to the traction of the platysma was experienced by most of the patients (190 patients, 76%). If the patient complains too much about this dimple, liposuction of the soft tissue with a sharp cannula will help but this may influence the result negatively.

Figure 2 and 3: The U and O shaped "purse-string" sutures pulling the SMAS, ESP and the parotid
fascia upwards. The location of "U" and "O" sutures (purse strings) externally

Advantages of this method
1- The "U" suture picks up the platysma and achieves a much better neck result.
2- The "O" suture collects the SMAS and the parotid fascia like a purse string without major
undermining
3- Less risk of facial nerve injury due to tightening of the SMAS which is achieved by
means of a purse-string formed plication with superficial bites and minimal undermining.
4- A natural look to the face is achieved by the direct pull of the aponeurosis vertically.
5- The fixation of soft tissue to cheek bones gives an extra fullness to the cheeks which
sometimes makes a malar implant unnecessary.
6- Less bruising and swelling because of a superficial (SupraSMAS) dissection.
7- Short operation and quick recovery time.

We were not able to find any disadvantages with this technique.

Conclusion:
This is a procedure where the soft tissue (SMAS, Parotid fascia and ESP) is plicated and fixed to the periosteum of the zygomatic bone. A deep dissection is unnecessary. The suspension achieved is in my opinion more stable compared to some SMASectomy techniques. The "Purse String " forming a plication of the SMAS is a safe, quick, and simple procedure with effective results suitable for younger patients (Baker7 I and II) with good skin conditions. Complication rates and recovery times are low. The procedure fills the cheeks and gives a more natural look than standard facelifts. Some young surgeons may be put off by complex procedures used for face lifts, such as deep-plane, subperiosteal, and composite rhytidectomies1. The deeper layers are not for beginners, they are risky and more extreme. This superficial procedure is a much safer surgery and avoids entering the deeper planes that could result in severe complications.

Figure 6: A 47 year old patient (Baker II) before and after surgery.

Figure 7: A 52 years old patient (Baker II) befora and after purse string formed SMAS plication.

Figure 8: A 55 years old patient (Baker III) before and after purse string formed plication of SMAS with fixation to zygomatic bone.