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ANATOMICAL STUDY
Superficial Fascia in the Cheek and the Superficial
Musculoaponeurotic System
Kun Hwang, MD, PhD and Jung Ho Choi, MDy
Abstract: The origins and validity of the term ‘‘superficial mus-
culoaponeurotic system’’ (SMAS) is reviewed. Gray stated the
superficial fascia connects the skin with the deep or aponeurotic
fascia and consists of fibro-areolar tissue. Hollinshead wrote super-
ficial fascia exists throughout the body and contains a variable
amount of fat. In the head and neck, it encloses voluntary muscles in
its deep portion. Skoog found superficial fascia was fixed to the
dense, deep fascia by fibrous adhesions in the temporal, preauri-
cular, and parotid area. Mitz stated ‘‘There is a ‘superficial muscular
and aponeurotic system’ (SMAS) in the parotid and cheek areas.’’
SMAS has an intimate relationship with the entire superficial fascia
of the head and neck and divides the subcutaneous fat into 2 layers.
Wassef found a continuous fibromuscular layer at the deep limit of
the ‘‘subcutis,’’ which corresponded to the ‘‘superficial fascia.’’
Nakajima reported the subcutaneous adipofascial tissue was made
up of 2 adipofascial layers. Macchi found 2 different fibroadipose
connective layers bounded to the laminar connective tissue layer
(SMAS). In the cheek, Hwang found horizontal fibrous connective
tissues (membranous layer of superficial fascia) divided the super-
ficial fascia into the superficial fatty layer and the deep fatty layer.
Recently, Mitz explained the reason for the term SMAS. The
‘‘musculoþaponeurotic’’ component is based on histology of mus-
cle cells, including the risorius, in the same structure to be surgically
consistent. The aponeurotic cells belong to the same surgical layer.
SMAS is not sufficient to replace the old term ‘‘superficial fascia’’
of the cheek area.
Key Words: Cheek, superficial fascia, superficial
musculoaponeurotic system, terminology
(J Craniofac Surg 2018;00: 00–00)
I n 2016, the ‘‘superficial musculoaponeurotic system’’ (SMAS)
was introduced into the Medical Subject Headings (MeSH) as a
From the Department of Plastic Surgery, Inha University School of
Medicine, Incheon; and yChoi’s Aesthetic Plastic Surgical Clinic, Seoul,
Korea.
Received September 13, 2017.
Accepted for publication March 7, 2018.
Address correspondence and reprint requests to Kun Hwang, MD, PhD,
Department of Plastic Surgery, Inha University School of Medicine, 27
Inhang-ro, Jung-gu, Incheon, 22332, Korea;
E-mail: jokerhg@inha.ac.kr
This study was supported by a grant from National Research Foundation of
Korea (NRF-2017R1A2B4005787).
The authors report no conflicts of interest.
Copyright # 2018 by Mutaz B. Habal, MD
ISSN: 1049-2275
DOI: 10.1097/SCS.0000000000004585
The Journal of Craniofacial Surgery  Volume 00, Number 00, Month 2018
Copyright © 2018 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
‘‘layer between the superficial fat compartment and superficial
facial muscles in the head and the neck.’’ As well known, the
MeSH database is made available and maintained by the US
National Library of Medicine National Institutes of Health.1
This step is thought to have been taken in response to 2 statistical
reviews conducted by Brazilian surgeons.2,3
Before considering whether it should be listed in Terminologia
Anatomica: International Anatomical Terminology (TA),4 the ori-
gins and validity of the term SMAS should be reviewed.
Gray’s Anatomy (15th Ed. 1901)
Henry Gray stated that the fasciae (fascia, a bandage) are fibro-
areolar or aponeurotic laminae, of variable thickness and strength,
found in all regions of the body, investing the softer and more
delicate organs.5 The superficial fascia is found immediately
beneath the integument over almost the entire surface of the body.
It connects the skin with the deep or aponeurotic fascia, and consists
of fibro-areolar tissue, containing in its meshes pellicles of fat in
varying quantities. Certain cutaneous muscles also are situated in
the superficial fascia, such as the platysma myoides in the neck, and
the orbicularis palpebrarum around the eyelids. He wrote that the
superficial fascia connects the skin to the subjacent parts, facilitates
the movement of the skin, serves as a soft nidus for the passage of
vessels and nerves to the integument, and retains the warmth of the
body, since the fat contained in its areolae is a poor conductor of
heat (Table 1).
Hollinshead (1954)
Hollinshead, in his book, wrote that the subcutaneous tissue of
the head and neck, usually referred to as the ‘‘superficial fascia,’’
resembles this tissue elsewhere in that it contains a variable amount
of fat; its distinguishing characteristic, as compared with subcuta-
neous tissue in general, lies primarily in the fact that it encloses
voluntary muscles in its deep portion (Table 1).6 Thus, the platysma
is embedded in this layer in the neck, while in the face the
connective tissue is denser and the muscles of expression lie within
it. The subcutaneous tissue of the head and face is rather tightly
attached about the muscles and to the underlying bone.
Pangman (1961)
Pangman performed face and neck rhytidectomy by utilizing
deep fascial sutures, deep temporal plane dissection, and submental
lipectomy.7 The incision he made in the temporal area was extended
down to include the superficial fascia, in contrast to the usual
technique (Table 1). This deep incision had certain advantages: it
facilitated dissection, which could mostly be done with the finger-
tip; there was less bleeding; and it allowed very firm fixation into
the deep temporal fascia in the lifted position.
Skoog (1974)
Skoog used the superficial fascia and platysma in facelift
surgery.8 He found that the platysma was intimately associated
with the skin and subcutaneous tissue of the entire anterior neck.
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TABLE 1. Terms used for Superficial Fascia in the Cheek
Author Superficial Layer
Grey (1901)
Hollinshead (1954)
Pangman (1961)
Skoog (1974)
Mitz (1976) Superficial to SMAS
Wassef (1987)
Nakajima (2004) Protective adipofascial system (PAFS)
Macchi (2010) Superficial adipose tissue (SAT)
Hwang (2016) Superficial fatty layer of superficial fascia (SFS)
SMAS, superficial musculoaponeurotic system.
The under-surface of the muscle, however, was not fixed to the
deeper structures, and a potential space was present between the
smooth fascia of the platysma and the external cervical fascia. He
thought that the platysma provided a corner-stone for rearranging
superficial neck tissues. In the face, the ‘‘fascial architecture’’ was
another reference point of reconstruction for him. In the temporal,
preauricular, and particularly in the parotid area, the facial, or deep,
fascia is distinctly defined, covering major nerves and vessels that
pass closely underneath (Fig. 1, left upper). In these areas, the
superficial, or subcutaneous, fascia is fixed to the dense, deep fascia
by fibrous adhesions (Table 1). Redundant skin and subcutaneous
fat in the buccal area droops and bulges at the melolabial fold, and
conversely, lateral advancement of the superficial fascia (buccal
fascia) within this area effectively takes up any slack at the angle of
the mouth and softens the pronounced melolabial fold.
To improve the wrinkles of the cheek and melolabial fold, he
innovated the superficial fascia rhytidectomy (Fig. 1, left lower).
Mitz (1976)
With regard to facelift procedures, Mitz defined the SMAS as
follows: ‘‘There is a ‘superficial muscular and aponeurotic system’
(SMAS) in the parotid and cheek areas.9 This SMAS is partially
described in Gray’s textbook of anatomy: ‘The facial muscles of
expression are cutaneous muscles lying within the layers of the
superficial fascia.’’’ He observed that the SMAS in the parotid and
cheek areas has varying thickness (sometimes thick, and sometimes
thin), but is always present.
He stated that the SMAS has an intimate relationship with the
entire ‘‘fascia superficialis (superficial fascia)’’ of the head and
neck. In particular, he proposed that the SMAS divides the subcu-
taneous fat into 2 layers. Superficial to it, small fat lobules are
enclosed by fibrous septa running from the SMAS toward the
dermis. Deep to the SMAS the fat is abundant; it lies between
deep facial muscles, and it is not divided by such fibrous septa. His
dissections showed that the SMAS is continuous with the posterior
part of the frontalis muscle in the upper part of the face, and with the
platysma muscle in the lower part of the face. He wrote that Gray
already expressed this point (Table 1).
Histologically, he observed that the SMAS can be composed of 1
to 3 layers between the parotid fascia proper and the skin. Because
muscular fibers are sometimes obvious within the fibrous layer, he
named it a ‘‘musculo-aponeurotic system.’’ In the cheek area, under-
neath the dermis, the SMAS is a continuous fibrous net sending
several extensions out to the dermis, thereby comprising all the
attachments from these muscles to the dermis (Fig. 1, middle).
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Superficial Fascia (SMAS)
Membranous Layer Deep Layer
Superficial facia
Superficial fascia
Superficial fascia
Superficial, or subcutaneous, fascia (superficial fascia)
SMAS Deep to SMAS
Subcutis
Superficial fascia Lubricant adipofascial system (LAFS)
Superficial fascia Deep adipose tissue (DAT)
Membranous layer of superficial fascia (MSF) Deep fatty layer of superficial fascia (DFS)
Wassef (1987)
Wassef performed a histological study of the head and neck area of
8 human adults, 6 human fetuses, and 3 monkeys. He found a
continuous fibromuscular layer in the humans at the deep limit of
the ‘‘subcutis’’ (Table 1).10 This layer was composed of the platysma
muscle, the parotid fascia, and a fibromuscular layer covering the cheek
and enclosing the risorius and the triangularis muscles. This layer
corresponds to the ‘superficial fascia’ in general anatomy and probably
to the partial fibrous involution of the primitive platysma of mammals.
Nakajima (2004)
Nakajima investigated subcutaneous adipofascial tissue over the
entire body, reporting that the subcutaneous adipofascial tissue is
made up of 2 adipofascial layers (Fig. 1, right).11 The superficial
layer (protective adipofascial system) is formed by the solid struc-
ture because it protects against external forces. The deep layer
(lubricant adipofascial system) is a mobile structure that lubricates
musculoskeletal movement (Table 1).
Macchi (2010)
In full-thickness samples of the parotid, zygomatic, meloolabial
fold, and buccal regions, Macchi found 2 different fibroadipose
connective layers bound to the laminar connective tissue layer
(SMAS).12 In the superficial fibroadipose layer, vertically oriented
fibrous septa connected the dermis with the superficial aspect of the
SMAS. In the deep fibroadipose connective layer, obliquely oriented
fibrous septa connected the deep aspect of the SMAS to the parotid-
masseteric fascia (Fig. 2, Table 1). In the parotid region, the mean
thicknesses of the superficial and deep fibroadipose connective
tissues varied according to the regions (1.63 and 0.8 mm, respectively
at the parotid area; 0 and 2.9 mm, respectively, at the melolabial fold).
The superficial fat pads are located adjacent to the facial mimetic
muscles, while the deep fat lies directly on the facial skeleton.12
Hwang (2016)
In our previous paper (2016), in the cheek, horizontal fibrous
connective tissues connected with the zygomaticus major were seen
as a continuous membrane (membranous layer of superficial fascia;
MSF).13 The MSF divided the superficial fascia (SF) into the
superficial fatty layer and the deep fatty layer (Table 1).
Mitz (2016)
Recently, in response to a plastic surgeon’s question, Mitz
explained the reason for naming this ‘‘layer’’ the SMAS.14 The
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FIGURE 1. Figures of the superficial fascia. Left: Skoog’s method of correction of
the aging face (From figures on p304 and p308 of Skoog T. Plastic surgery new
methods and refinements. Philadelphia: WB Sanders, 1974). Left Upper:
Subcutaneous anatomy of the face and neck pertinent to the described
technique for face-lifting, Left Lower: The subcutaneous fascia within the
buccinators area and the platysma are identified at their lateral borders. These
structures are freed on their deep surfaces and advanced in a postero-superior
direction. Middle: Original drawing of SMAS by Dr. Mitz (1974) (Reproduced
# 2018 Mutaz B. Habal, MD
Copyright © 2018 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Superficial Fascia and SMAS
FIGURE 2. Schematic drawing showing the basic pattern of organization of
subcutaneous tissue (A) and its changes in the parotid region (B), the cheek
region (C) and the nasolabial fold (D). From Figure 4 of Macchi V, Tiengo C,
Porzionato A, et al. Histotopographic study of the fibroadipose connective
cheek system. Cells Tissues Organs 2010;191:47–56. Reproduced with
permission.
‘‘musculoþaponeurotic’’ component was based on the histological
findings of muscle cells, which include the risorius muscle in the
same structure, to be surgically consistent. The aponeurotic cells
(fibrous and multilayered) belong to the same surgical layer.
He acknowledged that ‘‘Gray’s brilliant findings were focused
mainly on the parotid area, and did not include the platysma muscle,
which sits for me inside the SMAS structure.’’
His conception of the SMAS was a dynamic structure uniting
both hemifaces, thereby allowing the modulation of expression by
bilaterally assembling the mimic muscles, which was a revolution
in the physiology of human expression.
DISCUSSION
The SMAS is defined as the ‘‘layer between the superficial fat
compartment and superficial facial muscles in the head and the
neck’’ in the MeSH database. In this review, however, we estab-
lished that the term SMAS designates the superficial fascia in the
cheek area.
Mitz stated that he named the ‘‘superficial fascia in the cheek
and parotid area’’ as the SMAS because he observed muscle cells,
including the risorius muscle, and aponeurotic cells (fibrous and
multilayered) in the same surgical layer.
On sharing the personal communication of Dr. Mitz, we
intended to confirm the existence of muscle cell in the superficial
fascia. On observation of our histologic slides, we could see muscle
cells in the membranous layer of the superficial fascia as Dr. Mitz
described (Fig. 3).
with kind permission from Dr. Mitz V). Right: Basic structure of the subcutaneous
adipofascial tissue. Radiograph of a horizontal cross-sectional specimen of the
back in an embalmed cadaver (upper) and a fresh specimen from the same
region (lower). 1. cuboid fat; 2. honeycomb fascia; 3. striated fascia; 4. flat fat; 5.
superficial fascia; 6. deep fascia (From Figure 1 of Nakajima H, Imanishi N,
Minabe T, et al. Anatomical study of subcutaneous adipofascial tissue: a concept
of the protective adipofascial system (PAFS) and lubricant adipofascial system
(LAFS). Scand J Plast Reconstr Surg Hand Surg 2004;38:261–266.
Reproduced with permission).
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FIGURE 3. Histology of the cheek, inter-tragal notch level. Upper: 10. The
superficial fascia (SF) was located from the dermis to just superficial to the
parotid gland and masseter muscle (M). Horizontal fibrous connective tissues
which were connected with the zygomaticus major muscle (Z) were visualized
as a continuous membrane (membranous layer of SF, MSF). MSF divided the SF
into the superficial fatty layer (SFS) and the deep fatty layer (DFS). Middle:
100. Lower: 400. Muscle cells are seen in the membranous layer of the
superficial fascia (arrows).
An aponeurosis is defined as a sheet-like tendinous expansion,
mainly serving to connect a muscle with the parts it moves.
Histologically, we can find minimal evidence of aponeurotic cells
or an aponeurosis in the SMAS.
According to recent papers, as well as Mitz’s original descrip-
tion, the superficial fascia in the cheek area is generally composed
of 3 layers: a superficial fatty layer, a membranous layer, and a deep
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 Volume 00, Number 00, Month 2018
fatty layer (several terms have been used to denote the 3 layers by
Nakajima, Macchi, and Hwang).11–13
As Macchi stated, the superficial fatty layer (superficial fat pads) are
located adjacent to the facial mimetic muscles, while the deep fatty
layer (deep fat pads) lies directly on the facial skeleton.12 Thereafter it is
thought that the superficial fatty layer has intricate relationships
allowing for almost effortless and graded mimetic movement.
The continued pressure to the deep fatty layer against bone and
their relatively inert role as space-filling interfaces over which the
somatic muscles slide during mastication may explain their ten-
dency to selectively atrophy over time.15,16
Therefore, the term SMAS, although widely used without
knowledge of its origins or meaning, is not sufficient to replace
the old term ‘‘superficial fascia of the cheek area.’’ Regarding the
‘‘system’’ in the cheek and neck, Jost insisted that there are 2
systems: the primitive platysma and the sphincter colli profundus.17
In our previous review, the platysma most commonly inserted on
the cheek skin (57.5%), followed by the cutaneous muscles around
the mouth (18.6%), the mandibulocutaneous ligament or zygoma
(18.6%), and the parotid fascia or periosteum of the mandible
(5.3%).18
In the MeSH database, ‘‘superficial fascia’’ and ‘‘hypodermis’’
are entry terms for ‘‘subcutaneous tissue,’’ defined as follows:
‘‘Loose connective tissue lying under the DERMIS, which binds
SKIN loosely to subjacent tissues. It may contain a pad of ADI-
POCYTES, which vary in number according to the area of the body
and vary in size according to the nutritional state’’ (introduced in
2003).
It is not easy to develop a rigorous definition of a complex
concept. Following the Nomina Anatomica (NA) principles, each
structure should be designated by one term only, and each term
should be short and simple, and have some informative or
descriptive value.
Further skeptical discussion will be needed before incorporating
this conceptual term into the International Anatomical Terminology
(TA), and the definition in the MeSH database should
be reconsidered.
As Voltaire (1756) said, the Holy Roman Empire was neither
holy nor Roman, nor an empire. Analogously, the superficial
musculoaponeurotic system (SMAS) is neither aponeurotic nor
an entire system.
In our view, SMAS is not sufficient to replace the old term
‘‘superficial fascia of the cheek area,’’ because ‘‘superficial fascia
of the cheek’’ is really original and genuine over SMAS.
ACKNOWLEDGMENTS
The authors thank to Dr Thomas Byeong Chul Kim, MD, BCI
Aesthetic Plastic Surgical Clinic, for sharing personal communi-
cation, and Hun Kim, BHS, Department of Plastic Surgery, Inha
University School of Medicine, for efforts in making a table.
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# 2018 Mutaz B. Habal, MD
Copyright © 2018 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Superficial Fascia and SMAS
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