Revista Română de Anatomie funcţională şi clinică, macro- şi microscopică şi de Antropologie

Vol. XXI – Nr. 3 – 2022 REVIEW

A Study of the Face’s Superficial

Musculo Aponevrotic System

Ramona Paula Cucu1, M. Hinganu2, Mihaela Monica Scutariu3, Amelia Surdu3,

Dana Gabriela Budală3*, Corina Ciupilan2, Delia Hinganu2
“Grigore T.Popa” University of Medicine and Pharmacy Iasi, Romania
Faculty of Medicine
1. PhD student
2. Department of Morpho-Functional Sciences I
3. Department of Implantology, Removable Dentures, Dental Technology

A Study of the Face’s Superficial Musculo Aponevrotic System (Abstract):

As a result of a network of collagen, elastic, and fat fibers, the Superficial Musculo-Aponeurotic
System (SMAS) connects face muscles and dermis. Compared to the rest of the body, the face’s
subcutaneous morphology is the most structured. The forehead, parotid area, zygomatic region,
temporal region, cheek, infraorbital region, nasolabial fold, and lower lip all have SMAS-specif-
ic characteristics that distinguish them from other facial structures. Key words: SMAS, aes-
thetic medicine, SMAS-platysma face lift surgery, radiologic anatomy

INTRODUCTION or SMAS. Deep and superficial fat are sepa-

A superficial musculoaponeurotic system
(SMAS) in the parotid and cheek areas of the
face was discovered in 1976, separating super-
ficial and deep adipose tissue (1). The defini-
tions and descriptions of the SMAS have been
the topic of significant dispute in the literature
since then. A thorough understanding of re-
gional diversity within the face is required for
the implementation of surgical facelift proce-
dures (2,3).
Initially, the term SMAS was intended to
refer to an anatomical-surgical entity that is
distinct from the platysma muscles. The pri-
mary description was produced in the parotid
and cheek areas, which prompted numerous
surgeons to conduct dissection on all planes of
the face (4). However, terminology, definitions,
and descriptions of SMAS morphology are in-
consistent (5–7), with some studies even ques-
tioning its existence (8, 9).
Structure and Function
The platysma muscle, parotid fascia, and the
fibromuscular layer that covers the cheek make
up the superficial musculoaponeurotic system,
rated by this system, which has distinct mor-
phology for each region of the face. The SMAS
is located above the platysma’s muscular belly,
below the zygomatic arch. With the superficial
temporal fascia and frontalis muscle, as well as
the platysma muscle, the fibromuscular layer
(10). Face muscles are connected to dermis via
SMAS, which distributes and amplifies face
muscle action (11). Fascial and neck fascia are
intimately connected by this structure. A func-
tional role for expression is provided by the
SMAS, which Macchi et al. characterize as a
central tendon for coordinated muscle contrac-
tion of the face (12,13).
SMAS was initially described by Macchi
and colleagues as a continuous layer extending
from the parotid area to the nasolabial fold with
gradual regional weakening.The superficial
muscular aponeurotic system (SMAS) and the
parotid fascia were proved to be two distinct
entities, as Macchi et al. (12) and others have
similarly described (14, 15,16) previously.
However, Macchi and colleagues (12) observed
very little evidence of the platysma muscle in
the parotid tissue samples that were analyzed.
They reported an average SMAS thickness of

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 A Study of the Face’s Superficial Musculo Aponevrotic System
0.386 ± 0.113 mm. Further research by Erian
and Shiffman (17) showed that the bottom area
of SMAS exhibits substantial individual varia-
tion.
Embryology
The second arch mesenchyme, which migrates
and forms a pre-muscular lamina throughout
development, is the source of the superficial
face musculature. In the eighth week of devel-
opment, the pre-muscular laminae gives rise to
the mandibular, temporal, infraorbital, and cer-
vical laminae. In contrast to the SMAS, the
platysma muscle arises from the cervical lam-
ina that encloses lower regions of the parotid
gland and cheek (10).
The Circulatory System and Lymphatics
The transverse facial artery, which also feeds
blood to a large portion of the lateral malar area
of the face, is the source of the blood supply
for the Superficial musculoaponeurotic system.
This system obtains its blood supply from the
transverse facial artery. Due to the fact that this
artery travels straight through the SMAS, there
is a possibility that it will become transected
whenever the SMAS is elevated. In facelift
treatments, which are more formally referred to
as “rhytidectomy”, as well as in facial reconstruc­
tion after procedures involving parotidectomy,
SMAS elevation is a step that is performed. The
tiny lymphatic veins that are located deep to
the SMAS mostly drain into the preauricular
or submandibular lymph nodes, which are fol-
lowed by the anterior cervical chain as the final
destination for the lymph (18).
Nerves
The branches of the facial nerve, also known
as CN VII, are the most anatomically signifi-
cant nerves that are located in close proximity
to the superficial muscular aponeurotic system
(SMAS) as well as the face muscles and ac-
companying fascial layers. The facial nerve
emerges from the skull through a hole that is
located below the tragus of the ear. Following
its departure from the parotid gland, the facial
nerve’s proximal branches—most notably the
temporal, zygomatic, and marginal mandibular
nerves—follow a path that is situated deep in-
side the SMAS. (19).
The great auricular nerve is another nerve
that ought to be mentioned. This nerve starts
in the cervical plexus, travels inferiorly to bridge
the sternocleidomastoid muscle around 6 cen-
timeters below the auditory canal, and then runs
just deep to the SMAS following the path of the
external jugular vein. The sensory branches
that originate from the trigeminal nerve are the
sole nerves that travel superficially to reach the
SMAS (19).
Muscles
Different comments on regional continuity
of SMAS are clearly visible in the literature.
Mitz et al stated that there is superficial mus-
cular and aponeurotic system in the parotid and
cheek areas while Wassef et al found a con-
tinuous fibromuscular layer deep to skin (20).
According to the findings of Thaller and
colleagues, the SMAS is a separate structure
that covers the face and is attached to the fron-
talis muscle superiorly and the platysma infe-
riorly. According to the findings of Thaller et
al., the SMAS connects posteriorly to the per-
icondrium of tragal cartilage and the sterno-
cleidomastoid muscle on the mastoid bone.
Anteriorly, it is continuous with the platysma
muscle (14).
Because of the thin and curvilinear structure
of the SMAS mingling with some of the expres-
sion muscles and deep fascia of the face in
certain areas it is hard to follow non inter-
rupted course of this tissue.
In its deep component, the SMAS surrounds
the voluntary muscles and extends into the fib-
ers of the risorius, frontalis, and platysma mus-
cles, as well as the peripheral region of the
orbicularis oculi muscle (2, 3, 5). Despite the
fact that the SMAS and the expression muscles
are physically characterized as separate struc-
tures, they function as a single unit for all
practical purposes. The function of the expres-
sive muscles is accentuated by the SMAS. Im-
aging research conducted by Som et al. was the
first to discover SMAS (20).
It’s possible that the presence of muscle fib-
ers in the fibrous SMAS septa provides more
evidence for the hypothesis that the SMAS is
responsible for causing the overlying skin to
contract and give rise to wrinkles. As a result, the
superficial musculoaponeurotic system (SMAS)
not only acts as a system that connects the
mimic musculature and the skin, but it also has
the potential to act as an independent func-
tional unit. This feature might lend credence to
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 Ramona Paula Cucu et al.
the hypothesis that the SMAS originates from
the platysma muscle (18).
Variations in Anatomy
For the first time, Mitz and Peyronie char-
acterized the superficial musculoaponeurotic
system (SMAS) for the cheek area of human
adults (1). Several research on the SMAS’s
architecture have since been published, and
they’ve sparked a lot of heated debates. The
SMAS is a morphological representation of a
functional unit under the skin’s surface that
connects the mimetic muscles to the skin(3).
At the nasolabial fold (NLF) level, two SMAS
morphological types have been identified. The
NLF is an anatomical landmark and boundary
between the cheek and the upper lip and be-
tween the type I and type II SMAS. Morpho-
logically speaking.
Type I SMAS morphology is seen on either
side of the NLF in the area described by Mitz
and Peyronie, as well as in other investigations
that have followed. It encompasses the fore-
head, the parotid area, the zygomatic and in-
fraorbital regions as well as the lateral section
of the NLF with fibrous septa that enclose fat
cell lobules of type I SMAS. Because of their
combined dynamic qualities, the collagen mesh
and fat lobules serve as tiny viscoelastic fat
pads. There are two types of SMAS structures.
Type II SMAS structures cover the regions
between NLF 3 and type II SMAS structures.
Collagen, elastin, and muscle fibers are all
found together in Type II SMAS (3).
Due to the lack of consistent large-scale
cadaveric research using histological and mac-
roscopic dissection, there are multiple physio-
logic variations of the SMAS. The SMAS was
examined by Khawaja et al. in the course of 800
facelift surgeries. To describe the superficial
musculoaponeurotic fatty system (SMAFS), they
used the acronym SMAS instead. They came
to the conclusion that there are six distinct
SMAFS versions.
Fatty, fibrous, and membranous are just some
of the six different types of membranes that
may be found in the digestive tract. This study’s
findings are mostly based on the SMAS’s vari-
ety in the deeper fatty layers. Botox treatments,
steroids, or even a congenital abnormality may
be to blame for some of these variations. It was
shown that the variations in SMAFS had an
effect on the facelift surgery process and result.
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SURGICAL CONSIDERATIONS
Rhytidectomy, sometimes known as a face­
lift, relies heavily on the SMAS. The SMAS
can be surgically manipulated and tightened to
achieve total face rejuvenation. The SMAS is
more useful in the bottom third of the face than
in the midface. For the most part, the SMAS
has been used in cosmetic surgery to correct
the drooping of face fat as a result of aging.
The SMAS is elevated to a higher position
in order to raise the dermal and skeletal struc-
tures that are visible on the skin’s surface.
SMAS manipulation and dissection is reported
in at least half of all rhytidectomies, according
to case reports. As a result of these investiga-
tions, we can see the importance of the SMAS
in aesthetic and dermatological surgery treat-
ments (21-23).
The SMAS and other face muscles can be
implicated in a variety of disease processes in
addition to its aesthetic implications. Denerva-
tion and atrophy of the facial nerve can occur
in Bell palsy, myasthenia gravis, myotonic dys-
trophy, as well as various neoplasms. Lymphoma,
adenoid cystic carcinomas, and dermoid cysts
are three examples of these can­cerous disorders.
Affected facial muscles, such as the SMAS,
may show anomalies as a result of infection or
injury (24).
The SMAS has been the subject of various
anatomical investigations, as has been discussed
earlier. Even if its anatomical location and gen-
eral morphology and fundamental nomencla-
ture differ, there are still many discrepancies.
Even some scientists are skeptical about its
existence. Zygomaticus muscle investiture via
the SMAS is a major point of contention.
In histological investigations, Machi et al.
found that the SMAS does indeed infiltrate the
zygomaticus muscle, but Gassner et al. believe
that it does not. The continuation of the pa-
rotid fascia is another contradiction that is fre-
quently debated. The results of previous re-
search are mixed on this issue.
The SMAS, on the other hand, is a distinct
layer that sits just below the parotideomasse-
teric fascia or parotideomasseteric fascia. The
nasolabial fold’s position in regard to the upper
lip is likewise a contentious issue. However, the
majority of experts think that the nasolabial fold
continues and even extends into the orbicularis
oris. It’s nevertheless a fact that the SMAS is
 A Study of the Face’s Superficial Musculo Aponevrotic System

essential for the cheek muscles’ ability to work
together and maintain face suppleness and sup-
port. (25)
CONCLUSIONS
1. Multiligamentary fibrous support systems
are provided for facial dermis by a single
unitary structure known as facial SMAS.
2. It was demonstrated the existence of oral
SMAS and how it aids in the insertion of
the mouth muscular apparatus into the skin.
The regulated contraction and sphincter
function of the mouth muscles can be exer-
cised by SMAS.
3. The dissection of the zygomatic ligament is
essential to the proper mobility of the face’s
central region. In between the muscle layer
and the SMAS, the facial nerve branches are
found.
4. Connective and muscular tissue are inter-
mingled in the upper lip SMAS, with very
little quantitative variations between them.
Connective tunnels are also being built in
SMAS to accommodate the angular and buc-
cal arteries.
5. Understanding the SMAS idea and perform-
ing various forms of face surgery might ben-
efit from these anatomical results.

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* Corresponding author

Dana Gabriela Budală

e-mail: danab1978@yahoo.com

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