Aesth Plast Surg
DOI 10.1007/s00266-017-0921-0
I N N OV A T I V E T E C H N I QU E S
The Anterior SMAS Approach for Facelifting and for Buccal Fat
Pad Removal
Malcolm D. Paul1
Received: 4 January 2017 / Accepted: 27 May 2017
Ó Springer Science+Business Media, LLC and International Society of Aesthetic Plastic Surgery 2017
Abstract Having performed numerous varieties of SMAS
advancement including: plication, resection, flap elevation
with variable anterior deep dissection, the author has
developed a direct approach to the mobile anterior SMAS
which allows correction of midface descent, modest ele-
vation of the modiolus, jawline correction, and, where
indicated, direct access for buccal fat pad resection.
Level of Evidence V This journal requires that authors
assign a level of evidence to each article. For a full
description of these Evidence-Based Medicine ratings,
please refer to the Table of Contents or the online
Instructions to Authors www.springer.com/00266.
Keywords SMAS face lifting
Midface lifting
Buccal fat
pad removal
Introduction
Since the description of the SMAS (superficial musculo-
aponeurotic system) by Mitz and Peyronie [1], attention
has been directed to various approaches to provide an
important foundation for a longer-lasting facial
Presented in Poster Format at the Annual Meeting of the American
Association of Plastic Surgeons in Austin, TX—March, 2017.
Electronic supplementary material The online version of this
article (doi:10.1007/s00266-017-0921-0) contains supplementary
material, which is available to authorized users.
& Malcolm D. Paul
mpaulmd@hotmail.com
1 zygomatic branch of the facial nerve, both of which
Department of Plastic Surgery, University of California,
Irvine, 1401 Avocado Ave., Suite 610, Newport Beach, CA
92660, USA
FACE AND NECK SURGERY
rejuvenation compared to what was obtained with skin lifts
only. The evolution of techniques regarding the manipu-
lation of the SMAS began with short anterior dissections
[2] and has evolved to lateral SMASectomy [3], deep-plane
dissection [4], and high SMAS dissections [5–7] with flap
advancement to fixed structures. Each of these approaches
relies upon an incision in the non-mobile SMAS over the
parotid gland or slightly anterior to the parotid gland with
anterior and inferior dissection. The goal has been an
advancement of the mobile SMAS to the fixed SMAS and
in some techniques, to Lore’s fascia [8]. Yet, one of the
most popular approaches to the aging face is the use of
purse string sutures to provide vertical elevation of the
ptotic SMAS correcting the jawline and the anterior cheek,
the MACS lift [9]. Simple plication of the mobile to the
non-mobile SMAS [10] and vertical plication of the SMAS
[11] are also widely used. Important contributions to the
repositioning of ptotic soft tissues incorporating the SMAS
include the FAME procedure (Finger assisted malar ele-
vation) [12] and the subperiosteal approach [13]. A thor-
ough understanding of the relevant anatomy as described
by Mendelson [14] is crucial in safely performing these
procedures. The goal remains the same, i.e., a firm foun-
dation of SMAS, evenly dissected or plicated and advanced
to a higher level, mostly superiorly, but also posteriorly as
indicated by the clinical findings in each patient. Having
performed a wide variety of SMAS manipulations, I sought
a safe approach to midface, modiolus, and jawline cor-
rection. This led me to explore the safety of directly
opening the SMAS in front of the parotid fascia. This
technique has been used in more than 200 consecutive
facelifts with two temporary neuropraxias involving the
resolved in 4–6 weeks. An advantage of the anterior SMAS
flap dissection is that, frequently, only a skin pinch lower
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lid blepharoplasty is required as the midface fat is
advanced superiorly forcing herniated fat back behind the
globe and avoiding midlamellar lower lid surgery with its
associated risks of lid malposition, etc. Jacono [15] pub-
lished a similar approach without using hydro-dissection
for flap dissection, without fixation to Lore’s fascia, and
without using an anterior access for removal of the buccal
fat pads. His procedure was based upon a true vertical
vector short scar facelift.
Patient Evaluation
As in any planned surgical facial rejuvenation, a thorough
history and physical examination is a prerequisite to a
favorable patient experience and result. Comorbid condi-
tions are assessed, and appropriate medical clearance is a
prerequisite to any elective procedure. Anatomical findings
will differ in each age group. However, all patients who are
candidates for this procedure have the following clinical
findings.
Vertical lengthening of the lid–cheek junction or mid-
face ptosis
Cheek laxity
Prominent nasolabial folds
Jowl formation
Frequently, a downward turned modiolus
Irregular contour to the mandibular border
Prominent, ptotic, buccal fat pads are seen in many, but not
in all patients who are candidates for the anterior SMAS
facelift. Most commonly, prominent buccal fat pads are
seen in patients of Latin American, Asian, and Middle East
descent, but Caucasian patients frequently present with
similar anatomical findings, i.e., prominent, ptotic buccal
fat pads.
Of course, most patients require a direct approach to the
aging changes in their neck, but rejuvenation of the lower
third of the face and neck is not included in this
publication.
Preoperative Planning
Patients are examined in the sitting position, and the
planned vectors of correction are determined. The need to
add facial fat grafting is individualized as many patients
will have an impressive malar fullness when the anterior
SMAS is advanced and is anchored superiorly and poste-
riorly thereby avoiding the need to add fat. In heavy faces,
frequently, an anterior SMASectomy is performed to avoid
an overly thick anterior cheek after flap advancement and
inset. Clearly, we have come to understand that reversing
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Aesth Plast Surg
facial aging requires a combination of vector-based and
volume-based procedures [16]. Fat grafting may be needed
in other areas, for example, the temporal hollows, infra-
brow area, lower eyelids, deep anterior cheek fat com-
partment, jawline, and perioral areas. These additional
procedures are not described in the publication.
General Surgical Considerations
Over 90% of the 200 anterior SMAS facelifts were per-
formed on women, and more than 90% were performed
under oral sedation, oral analgesia, and local anesthesia
without the need for intravenous medications nor general
anesthesia. Not having an endotracheal tube in place is a
welcome benefit of performing these procedures under
local anesthesia. Patients are given oral antibiotics and
prednisone preoperatively which are continued for
5–6 days postoperatively along with oral analgesics and
sedatives as needed. Essential monitoring of vital signs is
provided throughout the procedure including blood pres-
sure, pulse, and oximetry. A monitor with the capacity for
providing a running EKG should be available, but is not
used routinely.
Surgical Technique
This procedure begins with the infiltration of buffered local
anesthesia utilizing both 1 and ‘% lidocaine with adre-
nalin, injecting the greater auricular nerve and injecting
along the planned incision lines with buffered 1% lidocaine
with adrenalin followed by injections of buffered ‘%
lidocaine with adrenalin through 22-gauge spinal needles.
The concentration of adrenalin is diluted 1–1 with lido-
caine without adrenalin in hypertensive patients or those
who become hypertensive after the first injections. Stan-
dard tragal edge or pre-tragal incisions (in patients who
have a sharp tragus and well-defined pre-tragal wrinkle) are
joined with a beveled temporal sideburn incision and either
a short or a full post-auricular incision with or without
extension into the occipital hairline as determined by the
amount of work to be done on the neck (Fig. 1). The cheek
dissection proceeds anteriorly into the mobile SMAS in
front of the parotid gland. At this point, after obtaining
pinpoint hemostasis, the anterior SMAS flap incision is
marked or an anterior SMASectomy is marked as an
ellipse. A key step to insure a safe dissection is hydro-
dissection and a bloodless field. In a patient who is having
this procedure under oral sedation and local anesthesia, the
flap is injected with, on average, 10cc of buffered ‘%
lidocaine with adrenalin. If the patient is under intravenous
sedation or under general anesthesia, normal saline can be
Aesth Plast Surg
Fig. 1 Goals and technique
injected to hydro-dissect the flap (Fig. 2). The flap is ele-
vated (after a strip of SMAS is excised in heavy, round
faces) (Fig. 3), and the dissection proceeds anteriorly while
applying traction on the flap with Allis-Adair clamps. The
dissection continues to the modiolus and over the malar
bone combining sharp dissection with curved long facelift
scissors (tips facing up) and blunt finger dissection. Verti-
cal dissection with the Trepsat elevator is very helpful as
well. The innervation to the zygomaticus major and minor
muscles is preserved as is the buccal branch of the facial
nerve seen running horizontally over the masseter muscle,
deep to the deep cervical fascia.
Hydro-dissection provides an important safeguard as it
separates the deep cervical fascia from the SMAS flap,
thereby protecting the buccal branch of the facial nerve. If
the buccal fat pad is to be excised, it is usually quite easy to
access it through the dissection by entering the buccal space
Fig. 2 Anterior SMAS flap incisions and hydro-dissection
Fig. 3 Anterior SMAS flap incision or SMASectomy
beneath the elevated anterior SMAS (Fig. 4). The dissection
is easier in older patients with lax fascia. In younger
patients, if not easily accessible through the anterior cheek
dissection, an intraoral approach for buccal fat pad removal
is direct and rapid. Fixation is extremely important and is
performed with interrupted or running sutures of 3-0 Vicryl
or 3-0 PDS (Ethicon, Sommerville, NJ, USA). The SMAS
flap is advanced to Lore’s fascia inferiorly and to the fixed
SMAS in the temporal area followed by linear advancement
in the pre-auricular area again to the fixed SMAS over the
parotid gland. Additional sutures are placed along the
posterior jawline and subjaw to further tighten the jawline
bringing the SMAS and the platysma fascia to the non-
mobile post-auricular fascia (Fig. 5). Skin flap inset, exci-
sion of excess skin, and closure without tension are routine,
and, frequently, the amount of skin to be resected is
impressive due to the advancement of the SMAS. Drains are
inserted for 48 hours (Fig. 6).
Postoperative Management
Most patients are discharged to the care of a responsible
adult and do not need to stay in an overnight facility. Older
patients, those with comorbid conditions, and those who
Fig. 4 Buccal fat pad dissection and removal
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 Aesth Plast Surg

Fig. 5 SMAS flap advancement and plication

Fig. 6 Facelift closure

Fig. 8 Pre-op and 1-year post-op anterior SMAS facelift

have undergone several procedures in addition to the
facelift may require and/or desire to stay in an overnight
facility with monitoring. Patients are seen the following
day for a dressing change, at 48 h for the second dressing
change and drain removal, at 1 week, 4–6 weeks,
3 months, 6 months, and at 1 year postoperatively. A
supportive dressing is worn for 5–7 days depending upon
the procedures that were performed on the neck. Patients
require oral analgesics for a few days, oral antibiotics for 5
or for 6 days, decreasing doses of prednisone (Medrol
Dosepak), and a liquid diet than a soft diet for the first few
days. If the buccal fat pads were removed intraorally,
patients are asked to remain on clear fluids for the first 24 h

Fig. 7 Pre-op and 2-year post-

op anterior SMAS facelift and
facial fat grafting

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Aesth Plast Surg
Fig. 9 Pre-op and 1-year post-
op anterior SMAS facelift and
lower lid blepharoplasties
and then full liquids for another day and are advised to
rinse with an oral antiseptic solution after each meal for a
few days. Sutures are removed at 1 week.
Pre-op and 2-year post-op results at 2 year are shown
(Fig. 7).
Discussion
A wide variety of approaches to the manipulation of the
SMAS have as their common goal, a harmonious rejuve-
nation of the aging face, an attempt to improve the lower
lid/cheek junction, improve the nasolabial folds, smooth
the lax anterior cheek, and address the jowls. Each proce-
dure has its proponent(s) and can reliably produce
impressive facial rejuvenation. It seemed logical to
approach the mobile SMAS directly adding safeguards
provided by hydro-dissection and a thorough understanding
of the anatomy [17]. The anterior approach to raising a
SMAS flap is very efficient in providing a vertical eleva-
tion of the midface, thereby avoiding a direct midface lift
through the lower eyelid or from a temporal approach with
or without the aid of an endoscope to assist in the dissec-
tion. Because the dissection begins more anteriorly, it has
an advantage over a high SMAS facelift because the dis-
section can quickly reach the anterior cheek and the
modiolus which will allow a direct access to buccal fat pad
removal and elevation of the modiolus. This procedure has
been performed in over 200 patients over 4 years (Figs. 8,
9). There were two cases of temporary neuropraxia
involving the zygomatic branch of the facial nerve, both of
which resolved in 3–4 weeks.
Conclusion
The anterior SMAS approach to facial rejuvenation pro-
vides a safe, reliable, and easily reproducible technique for
repositioning ptotic facial soft tissues while allowing for
modest elevation of the modiolus and direct access to the
buccal fat pads.
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