6 Clinical Applications of High-SMAS for Facial Rejuvenation in Chinese Patients
- jessilyntanhy9
- Oct 6
- 5 min read
Facial rejuvenation in Asian patients presents unique challenges due to anatomical differences such as wider, flatter faces, thicker skin, and robust retention ligaments. The high superficial musculoaponeurotic system (SMAS) face and neck lift, combined with subperiosteal brow-tail elevation, offers a tailored solution for addressing these challenges. Drawing on the clinical study by Wang et al., this article highlights six key clinical applications and provides technical insights valuable for surgeons.
Understanding the Unique Facial Anatomy
Chinese facial anatomy presents specific challenges for conventional Western-designed facelift techniques:
Wider and flatter facial structure with shorter zygomatic arches and flat zygomatic prominences.
Thicker and stiffer skin and retention ligaments, which may limit tissue mobilization.
Distinct muscular patterns: The lateral orbicularis oculi and platysma muscles are more prominent, while the lateral brow lacks sufficient elevator muscle, accelerating brow-tail descent.
These anatomical nuances necessitate modifications in SMAS flap design, dissection, and fixation to achieve effective and lasting rejuvenation.
High-SMAS Flap Technique
The high-SMAS approach allows precise mobilization of the superficial musculoaponeurotic system to lift both midface and lower face structures:
Dissection Boundaries:
Upward: flat with the lateral canthus.
Downward: approximately 2 cm below the mandibular margin.
Medially: across the zygomaticus major, prezygomatic, and masseteric spaces.
Zygomatic Ligament Release:
Blunt dissection of the zygomaticocutaneous and medial zygomaticus muscle ligaments increases SMAS mobility.
Enables effective elevation of malar fat pads, nasolabial folds, and jowl contours.
Platysma Management:
Platysma-auricular and suspensory ligaments are released to restore neck definition.
The SMAS-platysma flap is anchored to the postauricular mastoid fascia, transforming a descending muscle into a lifting vector for the lower face.
Buccal Fat Management:
Excess buccal fat can be partially excised and repositioned along the lower zygomatic edge to improve midface contour.
Fixation:
SMAS-orbicularis oculi flaps are secured to the deep temporal fascia.
Intermittent sutures ensure tension-free, stable repositioning without compromising facial nerve function.
Subperiosteal Brow-Tail Elevation
Addressing lateral brow descent is critical for periorbital rejuvenation:
Temporal Dissection: The temporoparietal fascia is separated above the deep temporal fascia, including the supratemporal septum and lateral orbital thickening.
Fixation: The temporoparietal fascia is anchored to the deep temporal fascia, effectively elevating the brow tail while avoiding direct muscle trauma.
Advantages: Minimizes scarring, preserves sensory nerve function, and allows predictable lateral brow lift in patients with limited natural elevator support.
6 Clinical Applications of High-SMAS for Facial Rejuvenation
1. Midface Rejuvenation
Clinical Challenge: Sagging malar fat pads, deepened nasolabial folds, and midface flattening are common aging signs.
Technique & Insights:
Elevate SMAS flap flat with the lateral canthus, extending medially and downward across zygomaticus major, prezygomatic, and masseteric spaces.
Release zygomaticocutaneous and medial zygomaticus muscle ligaments to improve mobility.
Reposition or excise buccal fat pads to correct midface volume and contour.
Clinical Outcome: Restores “apple-cheek” appearance with smooth nasolabial folds without overreliance on fillers.
2. Jawline and Lower Face Definition
Clinical Challenge: Jowls, marionette lines, and loss of mandibular definition due to platysma and SMAS descent.
Technique & Insights:
Release platysma-auricular and suspensory ligaments to mobilize the lower SMAS and platysma flap.
Anchor the flap to the postauricular mastoid fascia using intermittent sutures for vertical lifting.
Preserve the marginal mandibular branch of the facial nerve.
Clinical Outcome: Sharp cervico-mandibular angle, reduced jowls, and natural jawline redefinition.
3. Brow and Lateral Periorbital Rejuvenation
Clinical Challenge: Lateral brow ptosis accelerates periorbital aging and creates a fatigued expression.
Technique & Insights:
Separate temporoparietal fascia above deep temporal fascia and fix for tension-free lateral brow lift.
Include supratemporal septum and lateral orbital thickening in dissection to maximize lift.
Avoid sub-brow or upper eyelid incisions, minimizing scarring.
Clinical Outcome: Elevation of lateral brow improves eye shape, restores symmetry, and harmonizes expression.
4. Neck Rejuvenation
Clinical Challenge: Vertical platysmal bands, cervical laxity, and loss of jaw-to-neck definition.
Technique & Insights:
Dissect SMAS-platysma flap 2–3 cm below the mandibular margin to release downward traction.
Anchor to sternocleidomastoid fascia in postauricular region for stabilization.
Tension-free fixation and careful hemostasis reduce hematoma risk.
Clinical Outcome: Smooth neck contours, reduced platysmal bands, and rejuvenated cervico-mandibular angle.
5. Harmonization of Anterior and Lateral Face
Clinical Challenge: Flat zygomatic prominences limit anterior midface lifting with traditional SMAS approaches.
Technique & Insights:
Extend high-SMAS flap flat with lateral canthus for effective anterior lift.
Combine with temporoparietal fascia elevation to address lateral brow and temporal hollowing.
Strategically plan vectors to preserve natural muscle movement and avoid a “pulled” appearance.
Clinical Outcome: Balanced rejuvenation across midface and lateral face, restoring natural contours.
6. Adjunctive Interventions: Buccal Fat and Filler Integration
Clinical Challenge: Excess buccal fat or subtle nasolabial depressions can limit midface rejuvenation.
Technique & Insights:
Selectively excise or reposition buccal fat pads to enhance cheek contour.
Use small-volume fillers to smooth residual nasolabial folds or depressions.
Patient selection is critical—moderate aging changes and realistic expectations are ideal.
Clinical Outcome: Fine-tuned facial contouring without over-reliance on additional procedures.
Clinical Outcomes
Patient Satisfaction: Of 150 patients (28 with combined brow lift), 81 reported exceptional improvement, 29 much improved, 24 improved, and 16 unaltered. No worsened outcomes.
Complications: One temporary mandibular branch injury, two hematomas; no permanent nerve damage or flap necrosis.
Follow-Up: Median follow-up of 15.1 months demonstrated stable aesthetic results.
Practical Considerations for Surgeons
Anatomical Knowledge: High-SMAS dissection requires mastery of ligamentous boundaries, mimetic and masticatory muscles, and safe planes for nerve preservation.
Customized Approach: Tailor lifting vectors and fixation points to each patient’s skeletal and soft tissue anatomy.
Biplane Lifting: Combining high-SMAS with temporoparietal fascia elevation achieves comprehensive rejuvenation of midface, lower face, and brow-tail regions.
Postoperative Care: Expect temporary swelling at zygomatic prominences and temples, which typically resolves within 3–4 weeks.
Conclusion
High-SMAS face and neck lifts, combined with subperiosteal brow-tail elevation, offer a versatile and effective approach for facial rejuvenation in Chinese patients. By targeting six distinct clinical applications—from midface and jawline to brow and neck—surgeons can achieve natural, harmonious results while respecting the unique anatomy of Asian faces. Mastery of this technique allows precise correction of aging changes with minimal complications and long-lasting outcomes.
Reference:
Wang J, Xie L, Zhang N, Hu L, Wang J, Zhang S, Liu J, Wang X, Yan X. Clinical Application of the High Superficial Musculoaponeurotic System for Facial Rejuvenation in Chinese Patients. Plast Reconstr Surg Glob Open. 2025 May 12;13(5):e6775. doi: 10.1097/GOX.0000000000006775. PMID: 40356621; PMCID: PMC12068760.
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