IN THE PAROTID ‘YLADIER MITZ, Ml ‘THE SUPERFICIAL MUSCULO-APONEUROTIC SYSTEM (SMAS) AND CHEEK AREA MARTINE PEYRONTE, MD. Pars, France ‘There is a “superficial muscular and aponeurotic system” (SMAS) in the parotid and cheek areas. This SMAS is partially described in Gray's? textbook of anatomy: “The facial muscles. (mus. cles of expression) are cutaneous mus- cles Iying within the layers of the super- ficial fascia...” ‘A-careful study of the SMAS may lead to its proper use duting surgical procedures on the face. Thus, in this Paper, we consider both the anatomy and the potential surgical applications of the SMAS. MATERIALS AND METHODS ‘We studied 15 fresh cadavers, and in these we dissected 14 hemifacial, prepa- rations on 7 cadavers, aged 50 years or more. Then 3 heads were each serially sec- tioned in. one of 3 plancs—saxittal, frontal, and horizontal. Each scction was one cm thick. Prior to: the sectioning the vessels were injected with Radiocorredan"* (Fig. 5) to opacify the ‘very small arteries and veins. Zach sec- tion was then studied radiographically. Another 3 heads were similarly sec- tioned without preliminary injection and Xerayed, using an ultrathin focus (0.1 mm). ‘The histological specimens were stained with Masson's trichrome stain. (With this, the muscles stain red or black, the connective tissue. stains green) Thus, each preparation was subjected to dissection, arteriography in serial sec- tions, macrosections with macroscopic and ultraradiographic studies, and mi crosections with | microscopic studies, Particular attention was paid to the bor. der zones—tempororygomatic area, mai. dibula: area, nasolabial fold, and the pretragal area. ‘The dissections demonstrated the gen eral features of the SMAS. The radio. paque dye injections on the serial sec tions located the. avascular plane precisely. The ultraradiographic plates demonstraced the fibrous laycrs. The macroscopic (and, more importantly, the microscopic) sections demonstrated the delicate structure of the SMAS and its reladons with each Sbromusculet layer, EINDINGS ‘The SMAS in the parotid and cheek areas was always present, Sometimes it vas thick, and sometimes thin, and it was in intimate relationship with the entire fascia superficialis of the heat and neck. DESCRIFTION Gray? writes “On thé cheeks and Tips, it (the fascia. superficialis) contains & considerable amount of fat, and it # tougher and more fibrous especially in "The SMAS divides the subcutancou! fat in two layers. Superficial to it, small fat lobules are enclosed by fibrous sep# running from the SMAS toward the de mis, Deep.to the SMAS the fat is abu? dant, it lies between deep facial muscles and it is not divided by such fibrot, septa, resented at te maiting of the French Soclery of Flati Surgeons in October 1074, » 1 olOz FL 230 LELLSP9b LZ EES $Hd 391440 WIHOLIGa© sane | maninin afer the fat lying superfi- pas is removed ig fibrous 10 gal structure apparent (Figs. ibe parotidemasseteric aréa, the ip hi x and there it is attached sud sheath. Tee also sll pres- rote Ferrly, superficial to the facial Crilen as shown by our dissections and Finology studies. However, the SMAS isomer thin and discontinuous in the cheek a7e3, ‘In most of our dissections, when the ‘ealaver was more than 50 years old the SMAS appeared fibrotic. Therefore, we considered it as a fascia belonging to the ervicocephalic fascla (Couly et al"), tontinuous trom the head to the neck (ig. 2 center). Gray? writes “The su- perlicial fascia of the face is directly con- Hnvous over the mandible wieh thar of the neck Our dissections showed that the SMAS Is in continuity with the poster- ior part of the frontalis muscle in the upper part of the face (Fig. 2, center), E a with the platysma muscle in the pelallas Ba eae “| lower part of the face (Fig. 6). Gray’ 7 ema of the SMAS, The ervow soe Ceci cprened ivan peat These. Sheets ms cae an SEE acF, 2 lull) The continnoss line is the posterior muscular border of the SMAS, The Sees igs 2 supaor and anor imi, (center) "The ain ht Been neraovd, sowing SMAS in the parotid and check areas, (igh) Metaenbaum ween he SMAS and the parocia fascia. ia MNT Zo'd IS'LL OLOZ FL 230 IOLLSP9¥IZEX®4 Sd 3Ol44O WWIHOLIGR82 perlor and the inferior’ muscle attach- jaents of the SMAS probably have phys: fological implications, which we shall discuss. -MACROSCOPIG AND MICROSCOPIC STRUCTURE OF THE SMAS ‘The SMAS can be divided into two broad areas: the parotid area and the check area (Fig. 2, left). The Parotid Area Here the SMAS is 2 condensed mesh, distinct from the fascia of the parotid gland. Adherent in the ‘pretragal area for one or two cm, the SMAS then be- ‘comes separate from the parotid sheet (Figs. 3-7). ‘The microscopic sides showed that the SMAS can be composed of one to 8 layers between the parotid fascia proper and the skin, Sometimes the muscular fibers are obvious, within the Sbrous layer; hence the term musculo-aponeu- rotic system (Fig. 7). The Cheek Area Here the SMAS becomes thinner and can be followed microscopically. Under- “yx, 4. (le) The SMAB ie facial muscle (center, righ) The SMAS bas ‘otor branches have been preserve (errem 1 oloz FL 230 LOLLSP9R LZ EES ‘PLasTic a xzconsravorive sunosny, July 1976 a parodd aren mst respect the parotid fusca. TRE EMAS iba part of the fascie superpcials which ev Tends Hougoout the eorvicofacal afea, neath the dermis, the SMAS is a contin: ‘uous fibrous net sending several exterr sions out to the dermis (Figs. 4, 9, 10). This network constantly covers the fe cial muscles. The SMAS comprises all the attachments from these muscles to the dermis (Fig. 6). RELATIONSHIP OF THE SMAS TO OTHER FACIAL STRUCTURES Gray? writes “The superficial fascia (tela subcutenca) of the head invest the fecial muscles and carvies the super ficial blood vewels and nerves.” We! pulled, This has a stong efect on erechng ‘been cnected; Stensen’s duct and the $d 391440 WIHOLIGaVoi, 58,NovT / FActaL Tascxa Fe, 5: A macrosecton, with arteries injected by ‘adiocorrodam, View is of tha frontal” plsoe, Siough the veresl ram of the manaiole, The (ero inieues tho sveecolar plane where the BAS Bes. found this to be only partially true: the motor branches of the facial nerve lie deep to the SMAS. Nerves In the parotid area, only the sensory nerves (branches of the anterior cervical plecus) are located between the dermis and the SMAS. (Fig. 9). ‘The facial nerve and ite branches run deep into the parotid gland;. there they are pro- lected by the parotid fascia and the ex: ‘emal lobe of the gland. In the cheek ates, the facial motor ‘uerves run deeper than the SMAS (Fig. 4, right). Thus, the only nerves which 0 throngh the SMAS are the sensory erves; the motor. branches reach the st- Perficial Tayer of the facial muscles 'O'd 1 oloz FL 230 a3. through their deeper aspect. An impor- tant layer of fat is often located between the SMAS and the dernis; this mbcuta- neous fat is completely separated from Bichat'e fat pad by che SMAS (Fig. 8). Muscles ‘The SMAS invests and extends into the external part of the superficial facial muscles—involving fibers of the risorius, the frontalis, the platysma, and the pe- ripheral part of the orbicularis oculi (Figs. 1-6) - Pessels ‘The main vessels—the facial artery and vein—lie deep to the SMAS; their Fic, 6, Schema of a macosction through the premolat frontal plane. ‘The arrow points to the Ehtas, The OMAS is stretched up and dove by she fuperfeia) facial muscles, IOL{SP9FIZEX®4 Sd FDI44O TWIHOLIGR& snare u nrconsragerve.suncERY, Jul 1976 The Parotid Gland ‘in the prettagal area, the SMAS and tne parotid Bbrous fascia ze united 29 fof connective tissue. Here a Son of the SMAS is pos: Anterior 10 this ares, the io, 7. Scheraa of te Mas, (FAM =, frontal Smunde) D = Aeris BRE SSAS acy as a dstsibutor St ehe Halal rouse. so. sem of the Ronni HI 2 perforating bennches go through it an slab i out arta Pe perfor egal vascular network Ties 8S Oe Soc Geonatians males, 8 tae ego at. Thus, ene SMAS form toca mute, (ae pc. = pasos san 2h 4 Rerfmep order of the neurovascular pero at: > Or thi tin : = ne, gaugcular cutaneous COm=pleX Meanie Roary fF saascloaponsurae 69) ZSillL OLOZ FL 32 0 IOLESP9FIZEX®Y Sd 3Ol44O WWIHOLIGaol. 58,No.d | RACiAE FASCIA joinontal section of the" SMAS atthe ooler part of whe parotid gland. (x40) (elon) Schematic view. Gg erative nec, D— deer; So skin: PF = 2) Hlviontal sation of the, SOLAS aad d(x), (btem) dlentt te are ofthe study. (D decay Fat = facial muses Exp = cxpeneen of te SMAS so che akin) (Compare this with ee schema in Figure 8) Hine level of the nao 85 Temporazygomatic Area Here the SMAS crosses in front of the zygomatic arch and belongs to the tem- porozygomatic SMAS, ‘which adheres to the periosteum by thin expansions. The superior frontal branch of the facial nerve lies deep to the SMAS; the sen- tory nerve branches run between the MAS and the dermis: However, this space overlying the external part of the zygomatic arch is very narrow, co that dissection of the SMAS here is difficult and dangerous. A tetter plane of dissec. tion is found superficial to the SMAS, between it and the skin. Mandibular Area Here the SMAS is in’ close contact with the superficial fibers of the pi tysma, A safe plane of distection is found deep to the platysma and the SMAS, because the mandibular branch of the facial nerve runs deeper there. This plane has been cited by some au thors who use and elevate the platysma during rhytidoplasty (GuerreroSantos "We found loose fibrous connec: tions present between the SMAS and the periosteum of the inferior margin of the mandible, particularly in its ante: sor part, Mastoid Area ‘Here the SMAS is intimately attached. to the dermis and to the fibrous tissue ground the insertions of the sternoclavi:” cular muscles, It is rather difficult to iso- late the SMAS around the ear, because athe various fibrous layers are closely en- ewined. Nesolabial Fold (Fig. 10) ‘The SMAS is deep and is thin in this area} it is separated from the dermis by a large amount of fat, Several thin mus- cle expansions run forward, slanting from the SMAS to the dermis; it is diff IBLESP9FIZEX®4 Sd FOI44O WWIvOLIGaL 86 cult to trace one of these expansions to fan underlying facial muscle or to the ‘natolabial fold at the surface, This fold appears to be 2 cutaneous fold where the SMAS ends as a distinct layer, rather than.a fold caused by the insertions of specific muscles. REVIEW OF THE LITERATURE Gray’ describes the superficial fascia precisely. He docs not indicate that the fascia was tensed upward by the fron- talis muscle and tensed downward by the platysma muscle, and he does not point out any value in its surgical dissection. ‘Charpy’ discusses Gegenbaur'st and Fucamura's' deecriptions of the superfi- ‘cial muscular layers of the face. He does ‘hot asess clearly either the relations or the function of the SMAS. Podwyssoveky! describes the inser Hons of the facial. muscles in the decp aspect of the dermis; he sketches chem as numerous columns which are perpen: Gicular to the skin, snd he connects them toa superficial musculo-aponea- otic system. ‘Saban’ writes “The superficialis fas- cia, which covers the body, ends there- ford at the neck: its extension above the facial muscles would hinder all expression...” Farisse ef af have carefully studied the parotid fascia, looking for surgical applications in, otolaryngology. By com ‘ining dissections and histological sec- tions, they describe 5 layers in the paro- tid fascia: the subcutancous layer, the parotid layer proper around the gland, And the intraglandular layer, which di- ‘vides the gland into several compart jaents. However, they do not clearly assess the SMAS layer, and its muscular connections are not described. Couly et al? describe a corvicofacial fascia, withont pointing out the muscu- LOZ FL 230 LOLLSP9RIZENES pLasmic & REGONSIRUCHIVE suRoERY, July 1975 jar and dermal relationships of the SMAS, ‘They only consider this fascia to bbe a sliding system on the subcutaneous fat and periosteum. “To us the SMAS appears to be a fibro. muscular network located between the facial’ muscles and the dermis, one ‘which covers the facial niotor nerves. ‘Sech a double attachment between the muscles deep and the skin superf- cally through the SMAS does not hhinder the expressive function of thore muscles, but rather transmits it. The SMAS is Stretched Superiorly and Injeriorly (Fig. 7) ‘The SMAS is kept tensed superiorly by the superficial temporal muscles, the external part of che frontalis muscle, and the orbicularis oculi muscles. Tt is kept tense inferiorly by the platysma muscle Je i attached posteriorly to the tragus and the mastoid area, Such a periphera! stretching explains how the SMAS could ‘be an amplifier of the contractions of the facial muscles; che more it is temied, the less energy is necessary for the mut cle to transmit ite action (Figs. 6,7). The SMAS Transmits Facial Muscle 4¢ tion Through Two Directions ‘The SMAS acts as a distributor of at facial muscular contractions to the skit each muscle -contraction follows ont preferentiat direction in the networe Jn infinite number of resultant action} gre possible because (7) the SMAS re lays the contractions of the facial mut cies along the longitudinal network pit allel to the skin plane (Fig. 6) and the SMAS transmits the zesultant eff! in a perpendicular direction tows! ‘cial skin, through the fibrous «xP! sons from the SMAS to the der} Fig. 7)- “Thus, the human face has its wonde fa} ability. to express so many differs $Hd 391440 TWI¥OLIGayol.38,No.2 | FACIAL FARIA and shades of expression. Tt is mings co asrorne that each facil ruscle is specific for 2 particular facial expresion; rather, ‘each expression is the result of contractions of several mus- fles, wansmitted in combinations by the SMAS network to the skin. Aging weak- eng the elastic fibers of the SMAS and thus lessens the efficiency of the trans mission of muscle contractions to the skin, ‘The SMAS is quite an important ssructare for the plastic suy characteristics should be uti ‘wer possible. SURGICAL APPLICATIONS OF THE SMAS Meloplasiy i ‘The classic approach, undermining the skin superficial to the SMAS, de- stroys the fibrous connections between it and the dermis, It scems to us that an- other plane of dissection can sometimes be used deep to the SMAS; this proce: dure is anatomically possible and it is safe in the parotid area, but not anteri- erly. This deeper fascial dissection re pects the function of the SMAS, and it allows @ stronger pullback of the fascia and skin together (Fig. 4, left). When the excess part of the SMAS is resected and sutured to the pretragal area, the anterior muscles and the skin may be pulled back (er “lifted”). ‘This ap- roach also lessens the area which bas to be undermined, as only the parotid area has to he freed to obtain thie pullback. Facial Palsy The entire SMAS can be used in the palliation of facial palsy, where there 4s Ro fear of injury to the facial nerve. When we freed the SMAS forward to the ‘nasal fold on fresh cadavers, we ‘Were surprised at how much we could Seetch ‘the oral commissures (Fig. 4, 80d @S:lL OlOZ FL 230 87 DISSECTION OF THE SMAS GIGS. 2-9 Dissection underneath must be done very carefolly to aveid damage to the branches.of the facial nerve. Such an in- jury can occur during a. retrofascial itsection when (I) the SMAS is thin; (2) the superficial lobe of the parotid is short and does not protect the nerves; @) the retrofacial dissection is carried too far forward - (beyond the anterior border of the parotid gland) . ‘The dissection must start in front of the tragus, and can be done by inserting Mevzenbaiim scissors between the SMAS and the parotid fascia. The SMAS is freed carefully from this fascia, and this ‘becomes easy once the proper plane is found (Figs. 2, 8). ‘The dissection is not carried further upward than one cm below the zygo- matic arch, or lower than one cm above the inferior margin of the mandible. Once the SMAS is freed from the paro- tid fascia, it becomes possible to lift the face much more casily and strongly than by the usual simple skin undermining (ig. 4, left). ‘We have investigated the superficial musculo-aponeurotie system (SMAS) in the parotid and cheek areas by anatomi- cal dissections, by radiographs, and by nistological sections, ‘The SMAS may be helpful in correc: tive surgery for facial palsy and during face lifting operations if a’ retrofascial approach is used. This procedure, safe in the parotid area, can become danger- ous in the area anterior to the parotid gland, Vladimir Mitz, M.D. 93 Bd. Beawmarchais Poris 75003, France ‘Dr, Mite is Chit of the Clinic of the Hopitaux 6 Faris and Maytag MeCanil! Fellow in the Divi- Soa of Plastic Surgery atthe University of Minas in Miami, Florida, LOLLSP9R LZ EES $Hd 391440 WIHOLIGa60'd 88 AGENGWLEDGMENTS We thank Drs. F. Firmin, J. le Pasteur, A. Zea, Be Galicia, aod C Raye io hes ep guldance and encouragement this work, and Dr. Pr Tessier for Bis REFERENCES 1, Charpy, Au In Abrégé dldnatomio, Edited by Poirier, A. Charpy, and B. Cuneo, Dias: Son, Pasi, 108. 2% Gout, Cy Huser, To and Yalan, Js Ue ‘aperiilis”ca “kame chit pis zee we 4 Farin, J, at al: A propos do Venntomie chi- urpickle cea fegion parotidienae, CR. Dae Any 117; 254-261, 10% 4 Fummura, I: Uber ate envwicklung der facilis Tmuscalatur dot menichon. Anat ete, 30: 53-516, 1006 5 Casce, Re Fu The development of the facial pits in man J Anny 20 SE, 1066, @S:LL OlOZ FL 230 ‘FLasic & REcoNSrRVETIVE suRGERY, July 1975 LOLLS9¢ LZ & aye, Gs Zehrbuch der Anatomie dy “Sime, k chp lB pp. SE, Wi Edi engines Crip, 8 1, Samy Pet Troe de doco, BAe by» Genie haere oo # Gacy fe Hap 28 Moola 3 Rjdplony wile seioclag a tf Be pitgumy Roe, rectoa 20 Sk Sua ehiar Cong Fart tess Sep. Pn 1 8. Gris Rs anetony of the Mumen Doty, 2a ea ps Sek Tas A Sexier Paden oe! 10, Miz, Vy Las, J.P and Delecourt, As Bay, injection repletive par fesine coloree etm. Bogpague, Arch. Anat, Path 20: 335-138 ine 1, Podwysonsky: In ratte ¢ Anatomie Fumes, Heited by L, Testut, end A. Latarjet Dain Faris 198, 12, Test, Le and Latajet, As Traite @dnatomic Humaine. Doin, Paris, 1948, . J $Hd 391440 WIXOLIGR