Annals of Anatomy 227 (2020) 151414

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Annals of Anatomy
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RESEARCH ARTICLE

Platysma and the cervical superficial musculoaponeurotic system —

Comparative analysis of facial crease and platysmal band
development
T. Sandulescu, F. Stoltenberg, H. Buechner, H. Schmidt-Park, F. Linnerz, J. Jast,
M. Franzmann, T. Blaurock-Sandulescu, E.A. Naumova, W.H. Arnold ∗
Department of Biological and Material Sciences in Dentistry, School of Dentistry, Faculty of Health, Witten/Herdecke University, Germany

a r t i c l e i n f o a b s t r a c t

Article history: Objective: The superficial musculoaponeurotic system connects the mimic muscles to the skin, allowing
Received 21 May 2019 mimic expressions with regional morphological architectural differences. The aim of this study was to
Received in revised form 20 July 2019 perform an architectural analysis of the cervical platysma-skin interaction, determine the morphological
Accepted 5 August 2019
implications in platysmal band development and compare the findings to the facial SMAS architectural
types.
Keywords:
Method: Full-thickness blocks of skin, SMAS and platysma from seven hemifaces (three male and two
Superficial musculoaponeurotic system
female) and full-thickness blocks of skin, SMAS and mimic muscles of the periorbital, perioral, forehead
SMAS
Cervical superficial musculoaponeurotic and midfacial regions from six hemifaces (three male and three female) of donor bodies were collected
system postmortem. Serial histological sections were cut and stained with Azan. After the morphological analysis,
Cervical SMAS three-dimensional reconstruction of the tissue block was performed with AutoCAD. The morphological
Type V SMAS and mechanical properties of the different facial SMAS types were compared with those of the cervical
Platysma SMAS.
Platysmal bands Results: The architecture of the cervical SMAS (type V) consists of parallel, aligned septum fibrosus profun-
dus and septum fibrosus superficialis tissue connected by vertical, aligned septa fibrotica commisurales
tissue delimiting fatty tissue compartments transferring platysmal contractions to the skin. The facial
morphological dynamic mimic pattern (SMAS types I, II and III) describes the point-by-point transfer of
mimic muscle bundle contractions to the skin, explaining facial crease formation. The cervical morpho-
logical dynamic mimic pattern (SMAS type V) can be explained by dual traction force collimation over
the septum fibrosus superficialis and profundus in platysmal band development.
Conclusions: The cervical SMAS (type V) description supports the hypothesis that the SMAS and platysma
have different morphological origins. The two different facial and cervical morphological dynamic mimic
patterns support the phenotypical difference between facial fold and platysmal band development.
© 2019 The Authors. Published by Elsevier GmbH. This is an open access article under the CC
BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction
The superficial musculoaponeurotic system (SMAS) defines the
fibro-adipose network that connects the mimic muscles to the skin,
with regional morphological structural differences (Sandulescu
et al., 2018a, 2019a, 2019b, 2018b). The SMAS fibrous meshwork
transfers facial mimic muscle contractions to the skin, produc-
ing cutaneous creases (Sandulescu et al., 2019b). Previous studies
demonstrated close relationship between mimic muscle topogra-
∗ Corresponding author at: Department of Biological and Material Sciences in
Dentistry, Alfred Herrhausenstrasse 44, 58455 Witten, Germany.
E-mail address: Wolfgang.Arnold@uni-wh.de (W.H. Arnold).
phy and SMAS fibrous septa arrangement (Sandulescu et al., 2019a).
According to different mimic muscle topography and function dif-
ferent SMAS fibrous septa arrangement and regional architectural
differences have been demonstrated determining facial fold and
crease formation (Sandulescu et al., 2019b). Since its first descrip-
tion SMAS architecture was investigated and Ghassemi et al. (2003)
demonstrated two SMAS types covering the face medial (type
II) and lateral (type I) to the nasolabial fold. Latest investiga-
tions proposed a new SMAS architecture classification regarding
its interaction to the mimic muscles and dynamic processes such as
facial fold and crease formation: type I covering the praeparotideal
midfacial region lateral to the nasolabial fold and the forehead
region (Sandulescu et al., 2019b, 2018b), type II covering the upper

https://doi.org/10.1016/j.aanat.2019.151414
0940-9602/© 2019 The Authors. Published by Elsevier GmbH. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/
4.0/).
2 T. Sandulescu et al. / Annals of Anatomy 227 (2020) 151414

lip region medial to the nasolabial fold (Sandulescu et al., 2018b),

type III covering the upper and lower lid region (Sandulescu et al.,
2018a, 2019b) and type IV covering the parotideal midfacial region
(Sandulescu et al., 2019a). Praeparotideal type I SMAS consisted
of vertical arranged fibrous septa inserting into the skin, which
embrace singular mimic muscle bundles (Sandulescu et al., 2019a).
Type II SMAS fibrous septa bordered medial the nasolabial fold and
are shorter and stronger than type I SMAS connecting the orbic-
ularis oris muscle bundles to the perioral skin (Sandulescu et al.,
2018b). In contrast to type I type IV SMAS fibrous septa covering
the parotideal region were arranged parallel to the skin level due
to the lack of mimic muscles (Sandulescu et al., 2019a). Type I and
IV SMAS bordered the septum subcutaneum parotideomasseter-
icum (Pilsl and Anderhuber, 2010). Type III SMAS fibrous meshwork
connected the orbicularis oculi muscle superficial to the skin and
deep to the underlying fat compartments covering the eyelid region
(Sandulescu et al., 2018a).
The platysma is a mimic muscle that covers the cervical area,
showing many anatomical variations (Cardoso de Castro, 1984;
Hwang et al., 2017; Matarasso et al., 1999; Som and Laitman, 2017).
Platysma develops similar to the facial mimic muscles together
with the supplying facial nerve from sheet like laminae of pre-
myoblast and myoblast (Som and Laitman, 2017). Topographically, Fig. 1. Schematic overview of the cervical tissue block collection area (modified
the platysma can cross the mandibular line cranially, overlapping from (Radlanski and Wesker, 2012)).
the masseter muscle and inserting into the orbicularis oris muscle
(Fogli, 2008; Le Louarn, 2016; Widmalm et al., 1985). The platysma
This study aimed to both define the cervical SMAS as a structure
and the cervical skin have the same embryological origins (Fogli,
distinct from the platysma, and to develop a morphologically based
2008). The platysmal topography and its overlap with midfacial
explanation for the distinct phenotypical platysmal band and facial
regions and its relation to cervical fasciae might lead to the con-
crease aspects.
troversially discussed assumption that the facial SMAS originates
Toward this end, a histological architectural analysis and
from the platysma (Cardoso de Castro, 1984; Fogli, 2008; Ghassemi
three-dimensional reconstruction of the cervical platysma-skin
et al., 2003; Guidera et al., 2012; Levet, 2004; Wassef, 1987).
interaction and a morphological comparison with the different
Platysmal bands are one of the first signs of aging in the neck area
facial SMAS morphology types (types I, II, III and IV) were per-
and have a multifactorial developmental mechanism consisting of
formed.
muscular activity and tonicity combined with skin sagging (Alcala
The following hypotheses were set:
and Bravo, 2019; Trevidic and Criollo-Lamilla, 2017a). The develop-
ment of platysmal bands is controversially discussed as having two
etiological mechanisms: one of which involves platysmal contrac- 1 There is a cervical musculoaponeurotic system that connects the
tions during the aging process (Trevidic and Criollo-Lamilla, 2017a), platysma to the skin.
and the other of which involves skin sagging followed by the loss 2 The interactions among the cervical SMAS, platysma and skin
of platysmal tonicity (Barbarino et al., 2013; Henley et al., 2005; determine platysmal band development.
McKinney, 1996). According to the different etiological hypotheses, 3 There are morphological differences between the cervical SMAS
different therapeutic concepts with different outcomes have been and the different facial SMAS types that determine the different
adopted (Citarella et al., 2010; Guyuron et al., 2010; Kernt et al., facial crease and platysmal band phenotypes.
2011; Labbe et al., 2006; Sugrue et al., 2019). The absence of platys-
mal bands in patients with unilateral facial nerve palsy supports 2. Methods
the assumption that the formation of platysmal bands and platys-
mal contractions are closely related (Trevidic and Criollo-Lamilla, Five hemifacial (three male and two female) full-thickness tis-
2017a; Trevidic et al., 2015). sue blocks of the skin, SMAS and platysma and six hemifacial
Facial folds are classified into habitual folds, such as the (three male and three female) full-thickness tissue blocks of the
nasolabial fold, which are characterized by structural SMAS skin, SMAS and mimic muscles of the upper and lower eyelid,
changes, accidental skin formations without SMAS morphologi- parotideal and preparotideal midfacial, upper and lower lip and
cal changes, and age-related cutaneous redundancy formations, forehead regions were collected postmortem from donor bod-
such as upper and lower eyelid wrinkles (Sandulescu et al., 2019b). ies and post-fixed in 4.5% formaldehyde (Fig. 1; Table 1). The
Platysmal bands are phenotypically different from facial folds and donor bodies were embalmed by perfusion with 10% formalde-
appear because of muscle activity (Trevidic and Criollo-Lamilla, hyde immediately after arrival in the anatomical department.
2017a; Trevidic et al., 2015). The treatment of both facial folds The post-mortem time to fixation averaged between 24 and
and platysmal bands results in different outcomes, with frequent 48 hours. The donors were provided by the Department of Anatomy
platysmal band recurrence (Cotofana et al., 2015; Trevidic and II, Friedrich- Alexander-Universität Erlangen-Nuernberg and by
Criollo-Lamilla, 2017a). The poor long-term outcome after the the Department of Anatomy Universitätsmedizin der Johannes
treatment of platysmal bands, with recurrence within one year Gutenberg-Universität Mainz, Germany, and were official testa-
after the intervention, is, inter alia, caused by the inconsistent mentary donations from volunteers to the Department for use in
anatomical findings regarding the platysma-skin interaction and the anatomical student course for medical and dental students and
by the pathophysiological mechanism underlying platysmal band for medical research purposes. The study was carried out according
development, which remains terra incognita (Sugrue et al., 2019; to the regulations of the WMA Declaration of Helsinki in its present
Trevidic and Criollo-Lamilla, 2017a). form, as revised in 2013. The donor sites showed no visible scars or
 T. Sandulescu et al. / Annals of Anatomy 227 (2020) 151414 3

Table 1
Descriptive analysis of the body donor, sex and age and tissue collection sites.

Donor body Sex Age Hemi/full face Collection region SMAS type

1 Female 89 years Full face Cervical Cervical

2 Female 80 years Hemiface Cervical Cervical
3 Male 77 years Full face Cervical Cervical
4 Male 80 years Hemiface Cervical Cervical
5 Male 61 years Hemiface Cervical Cervical
Parotideal IV
80 Preparotideal, forehead I
6 Female Hemiface
years Upper and lower eyelid III
Upper and lower lip II
Parotideal IV
80 Preparotideal I
7 Female Hemiface
years Upper and lower eyelid III
Upper and lower lip II
Parotideal IV
73 Preparotideal I
8 Female Hemiface
years Upper and lower lip II
Forehead I
Parotideal IV
61 Preparotideal, forehead I
9 Male Hemiface
years Upper and lower eyelid III
Upper and lower lip II
Parotideal IV
80 Preparotideal I
10 Male Hemiface
years Upper and lower eyelid III
Upper and lower lip II
Parotideal IV
62 Preparotideal I
11 Male Hemiface
years Upper and lower lip III
Forehead I

tissue damage, and the medical history of each donor revealed no 3. Results
history of surgical intervention or radiation in the head and neck
area. 3.1. Cervical and facial regions

Macroscopic analysis of all cervical tissue blocks showed the

2.1. Histological analysis
After fixation in 4.5% formaldehyde, the tissue blocks were
embedded in paraffin, and serial histological sections in the vertical
plane were cut at a thickness of 5 ␮m. The sections were collected,
and every 10th section was stained with Azan. Micrographs of the
sections were collected using a Nikon D 7000 camera and a 105-mm
1:2.8D AF Micro Nikkor lens with a resolution of 12 megapixels. In
addition, the sections were investigated using a Leitz DMRB micro-
scope (Leica, Wetzlar, Germany), and additional micrographs were
collected.
2.2. Three-dimensional reconstruction of the cervical SMAS
Cervical tissue block 3D reconstruction and rendering were
performed using AutoCAD 2013 (Autodesk, Munich, Germany).
Photographs of the histological sections were consecutively
imported into AutoCAD 2013 and superimposed according to the
best-fit method. The outlines of the relevant structures were then
digitized, each in separate layers. A total of 270 histological sections
were digitized. Digitizing a single section required between 15 and
25 min, depending on the complexity of the traced structures. A 3D
wireframe meshwork image was created from each structure. By
digitally freezing or thawing individual structures (electronic dis-
section) (Machin et al., 1996), the three-dimensional architecture
of the SMAS structures and their relations to the mimic muscula-
ture and the skin were demonstrated. The 3D wireframe mesh was
imported into 3D Studio (Autodesk, Munich, Germany), rendered
into a model and visualized from various angles.
structure of the skin, cervical SMAS and platysma. Submandibular
gland tissue was detected in the serial sections of two donor bodies
(Fig. 2). The periocular (upper and lower eyelids), perioral (upper
and lower lips), preparotideal midfacial and forehead tissue blocks
showed the structure of the skin, SMAS and mimic muscles. The
parotideal serial sections consisted of skin and SMAS.
3.2. Histological analysis
3.2.1. Cervical SMAS
The skin, SMAS and platysma were identified in all serial histo-
logical sections.
The cervical SMAS connected the platysma to the skin. Morpho-
logically, the cervical SMAS consisted of a fibrous scaffold bolstered
with univacuolar fatty tissue. The cervical SMAS fibrous network
consisted of horizontally aligned septa connected by short vertical
septa. Three types of fibrous septa were found: septa aligned paral-
lel to the platysma and skin connected by vertically aligned, short
septa and intraplatysmal septa (Fig. 3); a continuous, epiplatysmal,
aligned fibrous septum covering the platysma (septum fibrosus
profundus) observed through all serial sections (Fig. 4); and a hor-
izontally aligned, fibrous plane between the platysma and skin,
superficial to the epiplatysmal fibrous septum (septum fibrosus
superficialis). The muscle bundles of the platysma, septum fibro-
sus profundus and septum fibrosus superficialis were connected
by vertically aligned fibrous septa (septa fibrotica commisurales).
3.2.2. Type I SMAS
The SMAS of the preparotideal midfacial and forehead regions
lateral to the nasolabial fold consisted of a vertically aligned, fibrous
septal network connecting the mimic muscles to the skin. The
4 T. Sandulescu et al. / Annals of Anatomy 227 (2020) 151414
Fig. 2. Micrographical overview of the histological sections obtained from the cervical tissue block. A = skin; B = cervical SMAS; C = platysma; D = submandibular gland.
Fig. 3. Micrograph of the cervical SMAS. 1 = parallel fibrous septum; 2 = vertical
aligned septum; 3 = SMAS fat compartment; 4 = intraplatysmal fibrous septum.
fibrous network compartments were bolstered with univacuolar
fatty tissue (Fig. 5).
3.2.3. Type II SMAS
Type II SMAS covered the upper and lower lips and consisted of
short, fibrous septa connecting the orbicularis oris muscle bundles
to the skin. The interseptal spaces were filled with univacuolar fatty
tissue (Fig. 6).
3.2.4. Type III SMAS
The upper and lower eyelids were covered by type III SMAS con-
sisting of fat-free, vertically aligned, fibrous septa connecting the
orbicularis oculi muscle to the skin (Fig. 7).
3.2.5. Type IV SMAS
Type IV SMAS covered the parotideal midfacial region and con-
sisted of aligned fibrous septa parallel to the skin level with short,
vertical, fibrous connecting septa. No mimic muscles were observed
(Fig. 8).
3.3. 3D reconstruction
3D reconstruction of the cervical tissue blocks was used to
visualize the three-dimensional interactions among the platysma,
cervical SMAS and skin (Fig. 9). Between the septum fibrosus pro-
fundus, platysma and skin, the horizontally aligned septum fibrosus
superficialis was observed as a continuous fibrous septum divid-
ing the cervical SMAS into two levels: the subcutaneous level and
the epiplatysmal level (Fig. 10). Septa fibrotica commisurales were
vertically aligned with respect to the skin level (Fig. 11).
4. Discussion
4.1. Method
The method of this study combines classical histomorphologi-
cal analysis with virtual 3D tissue reconstruction to reveal different
tissue interactions. The histologically assisted 3D reconstruction
method allowed in vitro analysis of the architecture of the SMAS
and platysma and their interaction, transforming a 2D morphologi-
cal analysis into a 3D visualization. The results achieved by digitally
freezing and thawing (Machin et al., 1996) the digitized layers of
the 3D reconstruction without dissecting or separating the different
structures macroscopically enabled a virtual histological autopsy.
The advantages of histologically assisted 3D reconstruction are
the histological detailed precision of the reconstructed volume and
the option of performing a virtual autopsy, which preserves the
morphological interactions among the layers.
There are several limitations to this study method due to the
use of serial histological sections. The reconstructed volume is
constrained by the size of the histological sections, and dynamic
interactions among different tissues can be only theoretically elab-
orated due to tissue fixation.
 T. Sandulescu et al. / Annals of Anatomy 227 (2020) 151414 5

Fig. 4. Micrograph of the platysma and cervical SMAS. 1 = epiplatysmal fibrous septum; 2 = intraplatysmal fibrous septum; 3 = vertically aligned SMAS fibrous septum;
4 = submandibular gland.

In conclusion, 3D reconstruction is a suitable method for rec-

ognizing and visualizing different tissue architectures and their
interactions.

4.2. SMAS morphology

Mimic muscles cover the viscerocranium and are connected to

the skin by a SMAS fibrous meshwork, which results in the pro-
duction of cutaneous creases during muscle bundle contractions
(Sandulescu et al., 2018a, 2019a, 2019b, 2018b). Earlier descriptions
of the SMAS as superficial fascia covering the facial and cervical
region (Gardetto et al., 2003) have been revisited by detailed func-
tional SMAS architecture analysis (Ghassemi et al., 2003; Lindner,
1986; Sandulescu et al., 2018a, 2019a, 2019b, 2018b). Later SMAS
investigation have demonstrated, that SMAS is a fibrous three
dimensional meshwork which connects the mimic muscle bun-
dles to the skin determining mimic expression and facial fold and
crease formation (Sandulescu et al., 2018a, 2019a, 2019b, 2018b).
SMAS implementation in clinical practice during head and neck
reconstructive and rejuvenation intervention determined the need
of a detailed morphological analysis of the regional differences
(Cardoso de Castro, 1984; Ghassemi et al., 2003; Sandulescu et al.,
2018a, 2019a, 2019b, 2018b; Wassef, 1987). The morphological
configuration and regional architectural variety of the SMAS deter-
mine facial fold development (Sandulescu et al., 2019b). This study
describes the type I SMAS, which covers the forehead and the midfa-
cial preparotideal regions lateral to the nasolabial fold region, type
II SMAS, which covers the perioral (upper and lower lips) region
medial to the nasolabial fold, type III SMAS, which covers the peri-
ocular (upper and lower eyelids) region, and type IV SMAS, which
covers the midfacial parotideal region confirming former study
results (Sandulescu et al., 2018a, 2019a, 2019b, 2018b). Former
results described facial SMAS as a single layered structure (Gardetto Fig. 5. Micrograph of type I SMAS (preparotideal midfacial and forehead regions).
et al., 2003; Mitz and Peyronie, 1976). In our opinion, regarding its SMAS fibrous septa connect zygomaticus major muscle bundles to the skin.
1 = zygomaticus major muscle; 2 = SMAS fibrous septa; 3 = SMAS fat tissue compart-
function in transferring mimic muscle contraction to the skin SMAS
ments.
three dimensional multiplanar fibro-adipose meshwork concept
described by this study results is justified.
The platysma is a multifunctional mimic muscle that covers the between the platysma muscle and the skin was described in former
cervical area with histochemical constitutional similarities to the investigation as the superficial fascia (Lindner, 1986). The superfi-
zygomaticus major, depressor anguli oris, levator labii superioris cial fascia covered the head and neck region embracing the facial
and levator anguli oris muscles, reflecting the phasic activity that mimic muscles and enclosing the platysma muscle (Gardetto et al.,
occurs during the expression of fast emotional reactions (Happak 2003; Lindner, 1986). Early studies assumed that the platysma
et al., 1988; May et al., 2018; Som and Laitman, 2017). The space develops from the SMAS (De la Cuadra-Blanco et al., 2013). The
6 T. Sandulescu et al. / Annals of Anatomy 227 (2020) 151414

results of this study demonstrate in analogy to the facial SMAS

architecture a fibro-adipose layer connecting the platysma to the
skin. The platysma has direct fibrous connections to the cervical
SMAS and to the skin via septa fibrotica commisurales, underly-
ing its function as a mimic muscle. Similar to SMAS terminology
and architecture cervical fascias and their relation to platysma
are controversy discussed reflecting the different international and
interdisciplinary differences (Cardoso de Castro, 1984; Davidge
et al., 2010; Guidera et al., 2012; Sandulescu et al., 2019a; Stecco
and Duparc, 2011; Wendell-Smith, 1997). The results of this study
combine morphological descriptive aspects with their biomechani-
cal dynamic function regarding SMAS three dimensional functional
unit concept developed in former studies (Sandulescu et al., 2018a,
2019a, 2019b, 2018b). Therefore, we implemented the former
described platysma fascia (Gardetto et al., 2003) into the SMAS
architecture as septum fibrosus profundus.
According to these findings, a revision of the SMAS typology and
nomenclature has been proposed.

4.3. New cervical SMAS nomenclature

Topographically and functionally, two types of cervical SMAS

fibrous septa have been described and categorized:

- Horizontally aligned fibrous septa: the septum fibrosus profun-

dus, aligned epiplatysmally, and the septum fibrosus superficialis,
which form a two-layer-SMAS architecture.
- Vertically aligned, connective fibrous septa: the septa fibrotica
commisurales connecting the platysmal bundles to the septum
fibrosus profundus, septum fibrosus superficialis and skin.

The spaces determined by the fibrous septa were bolstered with

fatty tissue, forming communicating compartments. There were
similarities between type IV SMAS and the cervical SMAS. Sep-
tum fibrosus superficialis and septa fibrotica commisurales showed
analogous alignment to the parotideal type IV SMAS architecture.
Still the morphological architectural dimorphism between type IV
SMAS and the cervical SMAS was determined by the platysma mus-
cle and the septum fibrosus profundus. Functionally, cervical SMAS
determined platysma bands formation by transferring platysma
muscle contraction to the skin showing functional similarities to
the facial SMAS types. Cervical SMAS architecture had different
fibrous septa arrangement than the other SMAS facial types. In con-
clusion, the cervical SMAS architecture was different than the facial
SMAS architectures (types I, II, III and IV); thus, type V SMAS nomen-
clature is proposed. Although the cervical SMAS and platysma are
closely connected, type V SMAS was recognized as a distinct struc-
ture from the underlying platysma.
The description of the type V SMAS morphology covering the
platysma in the cervical region could support the hypothesis that
the SMAS does not derive from the platysma (De la Cuadra-Blanco
et al., 2013; Ghassemi et al., 2003). Septum fibrosus profundus
close connection to the platysma muscle might have guided to the
assumption that platysma is embraced by its own fascia (Gardetto
et al., 2003). In our opinion septum fibrosus profundus connects
platysma muscle bundle contraction to the skin and therefore it
belongs to the cervical SMAS.

4.4. Cervical and facial SMAS biomechanical model

Fig. 6. Micrograph of type II SMAS (upper and lower lip regions). Type II SMAS
consists of a fibro-muscular meshwork bolstered with fatty tissue. 1 = orbicularis
Platysmal contraction results in an upward movement of the
oris muscle; 2 = SMAS fibrous septa; 3 = SMAS fat tissue compartments; 4 = muscle
cells in SMAS fibrous septa.
skin of the neck and influences the lower face mimic muscles by
dragging the lips inferiorly or posteriorly (de Almeida et al., 2017;
Fahmi et al., 2017; Hwang et al., 2017; Le Louarn, 2016). In contrast
to facial creases, contraction of the platysma produces platys-
mal bands (Sandulescu et al., 2019b; Trevidic and Criollo-Lamilla,
 T. Sandulescu et al. / Annals of Anatomy 227 (2020) 151414
Fig. 7. Micrograph of type III SMAS (upper and lower eyelid regions). Type III SMAS
consists of a fat-free connective tissue meshwork connecting orbicularis oculi mus-
cle bundles to the skin. 1 = orbicularis oculi muscle; 2 = SMAS fibrous septa.
2017a). Although platysmal bands are a characteristic and princi-
pal feature of the aging neck, their etiology remains controversial
and poorly understood (Sugrue et al., 2019; Trevidic and Criollo-
Lamilla, 2017a, 2017b). It is assumed that the pathophysiological
mechanism of platysmal bands is a multifactorial mechanism based
on muscular tone combined with cervical skin aging (Feldman,
2017; Gonzalez, 2009; Trevidic and Criollo-Lamilla, 2017a). Dif-
ferent cutaneous phenotypes and topographical locations could
be explained by different muscle contraction patterns (Alcala
and Bravo, 2019); however, the biomechanical development of
platysmal bands remains unknown. The following morphologi-
cal mechanical model was developed to explain the difference
between facial crease and platysmal band development.
7
Fig. 8. Micrograph of type IV SMAS (parotideal midfacial region). SMAS fibrous
septa are aligned horizontally, forming a fibrous meshwork bolstered with fatty
tissue. SMAS fibrous septa are connected by short, vertically arranged fibrous septa.
1 = horizontal SMAS fibrous septa; 2 = vertical SMAS fibrous septa; 3 = SMAS fat tissue
compartments; 4 = parotideal fascia.
4.5. Histomorphological mechanical model
Morphologically, the results of this study demonstrate that
platysmal contractions are transferred by SMAS fibrous septa to
the skin, similar to what occurs in the facial region. According
to the facial SMAS analogy, it has been assumed that platysmal
bands mimic the expression of platysmal contractions. While the
platysma and facial mimic muscles have histochemical similarities
(Happak et al., 1988), it was assumed in this study that the differ-
ent cutaneous phenotypes of facial creases and platysmal bands
are conditioned by the different SMAS architectures. Therefore, a
morphological mechanical comparative model between the cer-
vical and facial SMAS architectures was developed. Considering
the mimic muscle contraction forces transmitted to the skin level,
two different SMAS fibrous septal arrangements were recognized
and categorized after comparison of the different SMAS histological
8 T. Sandulescu et al. / Annals of Anatomy 227 (2020) 151414

Fig. 9. 3D reconstruction of the platysma and cervical SMAS (type V) showing the interaction and connection to the skin. 1 = skin; 2 = SMAS fibrous septa; 3 = platysma.

Fig. 10. 3D reconstruction of the platysma and cervical SMAS (type V) after digitally freezing the septa fibrotica commisurales. 1 = skin; 2 = septum fibrosus superficialis;
3 = platysma.

architectures (types I, II, III, IV and V): the facial type and the cer-
vical type. The fibrous septal arrangements of SMAS types I, II and
III represent the facial type, with vertical arrangements connecting
the mimic muscle bundles to the skin. The cervical type consisted
of horizontally aligned fibrous septa that were connected by short,
vertical fibrous septa, as described for types IV and V SMAS. The
lack of mimic muscles in the parotideal region led to the exclusion
of type IV SMAS from the mechanical model. According to these
findings, two different morphological dynamic mimic patterns are
proposed:
Facial morphological dynamic mimic pattern type a
The facial type (SMAS types I, II, and III) consists of parallel
fibrous septa vertically aligned with respect to the skin (mor-
phological dynamic mimic pattern type a, Fig. 12). Muscle bundle
contractions can be transferred singularly to the skin level, inducing
facial creases (Sandulescu et al., 2019a, 2019b).
Cervical morphological dynamic mimic pattern type b
The cervical type (type V SMAS) consisted of horizontally
aligned fibrous septa connected by shorter, vertically aligned
fibrous septa (morphological dynamic mimic pattern type b,
Fig. 13).
The septum fibrosus profundus and the septum fibrosus super-
ficialis represented an interface that concentrates and bundles the
multivectorial traction forces of the septa fibrotica commisurales
into a univectorial traction force. For SMAS types other than
the cervical type, singular muscular bundle contractions cannot
be transmitted point-by-point to the skin level. Platysmal con-
traction forces undergo dual collimation on the septum fibrosus
profundus and septum fibrosus superficialis and are transmit-
ted to the skin level as a force on a single plane, inducing
the platysmal band phenomenon. According to the mechanical
model, the existence of septa fibrotica commisurales (number, n)
amplified the collimating effect, decreasing the exerted traction
force.
 T. Sandulescu et al. / Annals of Anatomy 227 (2020) 151414
Fig. 11. 3D reconstruction of the platysma and cervical SMAS (type V) after digitally freezing the septum fibrosus superficialis. 1 = skin; 2 = septa fibrotica commisurales;
3 = platysma.
Fig. 12. Schematic overview of the interaction between the facial mimic muscle
bundles and the skin, showing skin relief changes between a relaxed condition
(1) and during a single muscle bundle contraction (2). F is the exerted single
muscle bundle contraction force transmitted by the vertical SMAS fibrous septa
to the skin. Green = skin; vertical blue lines = SMAS fibrous septa; round blue
lines = intramuscular fibrous septa surrounding mimic muscle bundles; red = mimic
muscle bundles (for interpretation of the references to color in this figure legend,
the reader is referred to the web version of this article).
4.6. Clinical relevance
Understanding the layered neck anatomy is crucial for perform-
ing reconstructive and aesthetic plastic surgery (Gassman et al.,
2017; Larson et al., 2014). A plethora of platysmal band thera-
pies based on botulinum toxin injection (Sugrue et al., 2019) or
on various surgical techniques for neck rejuvenation (Cardoso de
Castro, 1984; Citarella et al., 2010; Guyuron et al., 2010; Kernt
et al., 2011; Labbe et al., 2006) associated with complications
and problematic long-term outcomes, including band recurrence,
have been described (Knipper et al., 1997; Matarasso, 2014; Pelle-
Ceravolo et al., 2016; Ristow, 2014). Both botulinum toxin injection
and platysmal surgical techniques are based on regional circum-
scribed platysmal paralysis achieved by chemical denervation
(Sugrue et al., 2019) and resection (Kernt et al., 2011), respec-
tively. Therefore, we hypothesized that bordering platysmal muscle
9
bundle regions overtake the function after subcutaneous ablative
injectable therapy and produce new platysmal bands, explain-
ing band recurrence. The cervical morphological dynamic mimic
pattern type describes that a singular platysmal muscle bundle con-
traction is transferred to the skin level in a multiplanar manner,
inducing platysmal bands, which supports our hypothesis regard-
ing post-interventional band recurrence.
Connection of the platysma to the skin by type V SMAS could
also explain the observation reported by Trévidic, i.e., that the neck
skin follows the location and action of the platysma (Trevidic and
Criollo-Lamilla, 2017a). Together with the cervical morphological
dynamic mimic pattern, these findings also support the theory pro-
posed by Trévidic, i.e., that platysmal bands are caused by muscle
activity (Trevidic and Criollo-Lamilla, 2017a).
In a previous study, a morphologically based facial fold devel-
opment mechanism was proposed (Sandulescu et al., 2019b).
Habitual folds based on SMAS architecture changes were described,
while accidental folds were observed without SMAS morphological
changes and age-related facial wrinkles (Sandulescu et al., 2019b).
Accidental folds were described statically, showing no SMAS mor-
phological changes. By applying the facial morphological dynamic
mimic pattern model to the static architectural description, we
deliver one possible morphological dynamic explanation for acci-
dental facial fold development.
In summary, the platysma and cervical skin are closely con-
nected by the cervical SMAS (type V), which supports previously
reported observations (Fogli, 2008; Trevidic and Criollo-Lamilla,
2017a).
The results of this study together with the proposed facial and
cervical morphological mimic dynamic pattern allow the conclu-
sion that facial mimic muscles and platysma have no embracing
fascia. SMAS fibrous septa connect mimic and platysma muscle
bundles to the skin determining the mimic expression variety. The
assumption that platysma is covered by a fascia (Gardetto et al.,
2003) corresponding to the septum fibrosus profundus described
in this study is from the descriptive point of view morphological
and architectural correct. Though, biomechanically septum fibro-
10 T. Sandulescu et al. / Annals of Anatomy 227 (2020) 151414

Fig. 13. Schematic overview of the interaction between the platysmal muscle bundles and the skin, showing skin relief changes between a relaxed condition (1) and
during a single muscle bundle contraction (2). F is the exerted single muscle bundle contraction force transmitted by the SMAS fibrous septa to the skin. Green = skin;
a = septum fibrosus superficialis; b = septum fibrosus profundus; vertical blue lines, c = SMAS septa fibrotica commisurales; vertical blue lines, d = interplatysmal septa fibrotica
commisurales; round blue lines = intraplatysmal fibrous septa surrounding muscle bundles; red = platysmal muscle bundles; n = number of SMAS septa fibrotica commisurales
(for interpretation of the references to color in this figure legend, the reader is referred to the web version of this article).

sus profunduds like septum fibrosus superficialis belong to the
cervical SMAS bundling multivectorial traction in univectorial trac-
tion forces.
4.7. Study hypotheses and conclusions
This study describes the cervical SMAS architecture type V. The
systematic histological analysis of type V SMAS and description
of the septum fibrosus profundus, septum fibrosus superficialis
and septa fibrotica commisurales and their interactions with the
platysma and skin facilitated the development of a morphological
mechanical approach to explain platysmal band formation, sup-
porting our first and second hypotheses.
The topographical and architectural differences between type
V SMAS and the facial SMAS types (I, II and III) and the similari-
ties of the parotideal SMAS type IV and type V SMAS architectures
might determine the cutaneous phenotypical differences between
facial creases and platysmal bands. Together with the facial and
cervical morphological dynamic mimic pattern model, an approach
for elucidating platysmal band development and the phenotypical
differences between platysmal bands and facial creases support-
ing our third hypothesis was proposed. The cervical morphological
dynamic mimic pattern supports the close relation between platys-
mal band development and muscle contraction, as described by
Trevidic et al. (2015).
In conclusion, the results of this study support the hypothesis
that the facial SMAS does not represent an evolutionary platysmal
metamorphosis, as assumed in previous studies.
The facial morphological dynamic mimic pattern model pro-
vides an explanation for accidental facial fold formation.
Considering the facial and cervical morphological mimic
dynamic pattern we concluded that facial mimic muscles and
platysma have no embracing fascia. SMAS was a 3D functional unit
covering facial and cervical area fulfilling the function of a mimic
muscle inserting tendon into the skin.
Author contributions
TS wrote the manuscript.
FS performed the cervical SMAS 3D reconstruction.
HB performed the preparotideal SMAS analysis.
MF performed the upper eyelid SMAS analysis.
TBS performed the lower eyelid SMAS analysis.
JJ performed the forehead SMAS analysis.
EAN revised the manuscript.
WHA supervised the project and final manuscript approval.
Ethical declaration
The study was carried out according to the regulations of the
WMA Declaration of Helsinki in its present form from 2013.
Acknowledgements
We thank Susanne Haußmann for her technical laboratory
assistance in preparing the serial histological sections. We thank
the internal research promotion of Witten/Herdecke University
(Interne Forschungsförderung, IFF) for granting technical labora-
tory assistance (project number 2018-67).
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