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SMAS vs. Deep plane

Postby harri » Tue Nov 27, 2007 10:47 am

Dr. Hamra gives a nice summary of various facelifting techniques in his book titled, “Composite Rhytidectomy.” His summary includes the “Subcutanous Rhytidectomy, which is skin reduction only; the “Subcutaneous Rhytidectomy using the SMAS technique” which is skin reduction and platysma repositioning; “Deep-plane Rhytidectomy”, which is skin reduction, platysma repositioning and cheek fat repositioning; and “Composite Rhytidectomy” which is skin reduction, platysma repositioning, cheek fat repositioning and orbicularis repositiong.


This text explains the original diagram I think (although it misses out the Skoog stage which was developed into the deep-plane).

Image
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deep plane vs. SMAS harri

Postby suekk » Tue Nov 27, 2007 1:02 pm

harri, Again, thanks for all your help. I just read something in your last post that I have a quesiton about, and I have seen it mentioned recently on several other posts. Is the cheek fat repositioing done at all with any type of SMAS? Did you have any done with your extended SMAS?
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Postby harri » Tue Nov 27, 2007 1:15 pm

http://www.utmb.edu/otoref/Grnds/Rhytid ... 3-0521.pdf

This had a better pix of the flap diagram.

Facelifts are essentially a lift of the lower face and I don't think the standard smas lift lifts the malar fat pad.

The extended smas does but I think Dr Yang posted a study where Hamra said it was only a short term gain (2 years) and a long term failure. I'm not clear whether this applies to his composite method too?

I know a UK surgeon who does the modified Baker smasectomy uses fat grafting instead of soof or malar lifts. Perhaps they don't stay up?

Miss J has mentioned Sheryl Aston's FAME technique but I can't recall the details. Something to do with finger assisted malar.......?

THe MACS has a vertical element which lifts the cheeks and the smasectomy is positioned over the malar arch so that probably does but real midface elevation is a different procedure (and it's very controversial).
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Postby harri » Wed Nov 28, 2007 2:34 am

With the flaps elevated, the suspension of the SMAS is accomplished with either plication or imbrication. Plication implies sutures that fold the SMAS onto itself to shorten it, where imbrication involves excising a block of SMAS and approximating the cut edges to tighten this layer. Imbrication does not provide any additional benefit according to cadaver studies by Webster, and involves an additional step.


I'm not sure how a surgeon can evaluate plication v imbrication :?:

Dead people don't walk about so is this research valid?

However, I'm not convinced it's that big a deal.

The thing we always have to remember when we evaluate facelift techniques is that everything is a matter of opinion, not fact.
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Postby atlanti » Wed Nov 28, 2007 6:08 am

Harri - well now I am totally confused. Am in mid-fifties and had an SMASectomy - to include submental lipo under chin and neck lift - but it appears that my scars are identical to the SMAS - in the tragus, up behind the ear and into the hairline for the neck. This was done by one of the top UK surgeons BJ. It would appear that "terminology" is used differently by different people. But it would seem that the SMASectomy is gaining ground in the Uk also.
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Postby harri » Wed Nov 28, 2007 8:02 am

The scars are much the same - I think Baker says he may have to switch to a longer scar in certain patients during the op. I suppose it depends on how much excess skin there is in the neck.

Do you have a little scar under the chin in the middle? That's where they usually go in to tighten the central neck muscle (and the lipo I think). Otherwise he may have just tightened the ones by the ears (see Dr Yang Explains blog). It seems he has dome a smasectomy with a 'proper' necklift (for want of a better word).

I think the smasectomy has to have the inverted L at the top of the ear (which preserves the sideburns) because the lift is vertical there and excess skin has to be removed. I think my extended smas scar has removed some of my sideburns (wish i'd checked my hairline before my op).

But you can't tell the lift from the scars.

We'd love to hear your BJ story on lookyourbestuk. We talk about him quite a lot. :lol:

At least he named your lift - one poster had to try and decipher her op report. He says he doesn't like labels.
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Postby atlanti » Wed Nov 28, 2007 9:12 am

Thanks for that explanation Harri. I don't have the scar under the chin - but then my neck was in pretty good shape anyway - just a little fat under the chin. It was written down as SMASectomy + neck. I still have my sideburns!!! Tightness is in front of ears, not behind, and below towards outside of neck but not centrally . And you're right I don't think he likes labels but tends to tailor each op to the patient. I will check out your website. This board has been a godsend to me.
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Postby harri » Wed Nov 28, 2007 11:55 am

After much research my conclusion is:

Denenberg describes the smas plication lift which Dr Naderi doesn't like (plication sutures cut thru like cheese cutters cut thru cheese).

Dr Yang describes a smasectomy (like Baker lateral smasectomy)

Dr Naderi describes a standard smas lift ie sub smas which means first a skin flap is elevated and then the surgeon goes under the smas to elevate a smas flap. He calls this the smas imbrication lift or modified composite.

The deep plane is really just the extended smas where the smas is undermined nearer to the nose (ie it's a bigger smas flap).

The standard and extended smas lifts are 2-layer lifts, first the skin and then the smas are raised separately in flaps.

The other meaning of deep plane is from Skoog/Hamra but this evolved into the composite lift. The major difference is that it is a 1-layer lift (a unified flap that consists of skin, platysma, midface cheek fat and orbicularis) is raised and re-positioned in one chunk). Scary!

The other use of the term deep plane is subperiosteal (cut to the bone) but this is a midface lift.
Last edited by harri on Wed Nov 28, 2007 12:51 pm, edited 1 time in total.
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deep plane vs. SMAS harri

Postby suekk » Wed Nov 28, 2007 12:34 pm

harri,
what would your thoughts be if a doctor said he routinely does an extended smas with a mid-face lift on all his patients? Wouldn't this be a huge undertaking, filled with lots of risks? Please lend me your ear on this one. Thanks
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Postby harri » Wed Nov 28, 2007 12:47 pm

Are you talking about Dr V in Lithunia?
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deep plane vs. SMAS harri

Postby suekk » Wed Nov 28, 2007 1:24 pm

No, this doctor is in the states.
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Postby harri » Wed Nov 28, 2007 1:56 pm

It depends what you know about the doctor's reputation although it sounds a bit drastic. A lot of doctors don't like the midface lift (subperiosteal or any other really). It's very controversial and some say works no better than fat grafts.

You have to be careful reading the boards because sometimes the unhappy patients go underground.

There a DR Marten who does the 'works' (whatever that is) and there are quite a few unhappy patients who realilse they shouldn't have had surgery so young but most of the time he gets a glowing report.

There's also A DR Y in Boston who was a star until the unhappy patients were brave enough to post (I know a very unhappy one of his from the UK).

Mainly I'm saying be very careful in your choice of surgeon and don't believe all you read on the boards.

Ramirez comes up for the subperiosteal midface.
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Deep plane vs. SMAS/ Dr. Yang

Postby suekk » Wed Nov 28, 2007 2:19 pm

Actually harri, I read your note, and then looked up at mine, and I mis-
spoke. This doctor does deep plane facelift, mid-face lift, and fat grafts. It sould like so much. I agree, I would think alot of unhappy people are too sad to post.
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Postby MissJ521@aol.com » Wed Nov 28, 2007 7:23 pm

Harri,
I goes SOMETHING like this:

SMAS plication starts with a skin dissection to expose the SMAS and to the SMAS, the fold it over on itself like in 'darting' material when sewing and dart it towards the ear. This type of 'darting' action lifts up the SMAS in a diagonal like 'vector' and does not involve going under the SMAS to slide it as a separate flap. Meanwhile, the skin, since it is dissected to expose the SMAS underneath, can then be slid up as a separate flap and then some is cut off. In this way, most of the tension is on the SMAS and not the skin and you don't get a big tension skin scar at the incision. A 'mini' or Lifestyle type lift is one where in GENERAL, they do some SMAS plication but not that much as you can only plicate as much SMAS as can be exposed by skin dissection. In the mini lifts, not enough skin dissection is done to release the skin as separate flap or to plicate a lot of the SMAS in 'darts'. Instead, they do sort of a purse string suture to mobilize the SMAS. The non 'mini' or 'instant' or LSL type SMAS plication is one where they peel down enough skin to dart a lot of the SMAS and the darting and folding over on itself helps lift the whole of it up. The mini type lifts use the SKIN attachment (un dissected part) to HELP PULL UP or tug at the REST of the SMAS. In this way there is some more TENSION and the scar can be 'taxed' with too much holding up to do and you can get a big hypertrophied scar. Hence just not doing the mini and doing the SMAS with a better dissection.

When the PSs talk in terms of SMAS 'imbrication', this can involve still dissecting skin and enough of it but also dissecting a little bit of UNDER the SMAS and enough that a strip of SMAS can be excised or even folded onto itself but closer to the ear. In this way, a whole bunch of 'darts' are not made. The small part where they go UNDER the SMAS is technically 'deep plane' but is not called that. It's just termed SMAS imbrication.

With the Baker type SMAS excision, it's just excised in the middle somewhere and the rest of the sections are attached together. This helps pull up the face too.

Technically speaking when ever the doc goes UNDER the SMAS 'plane' (but not quite to the bone), it can be called 'deep plane'. But when they go under a little of the SMAS, it's just something they 'do' and don't market or call it 'deep plane'. For example, one would want to (sometimes) go UNDER the SMAS where the platysma muscle is which is on the lower face AND neck and in that region, it could be called deep plane or part deep plane but still docs who do that don't call it 'deep plane' but may do that for their results.

SMAS ectomy--the ectomy part means 'to cut out'. So SMASectomy refers to cutting out part of the smas. Does not matter where it is cut. If some if it is cut out ("ectomy"), that's what the word means. (Some Ancient Greek and Latin comes in handy with medical terms even if one gets lost reading Homer in the Greek LOL)

The only way to really find out is to read the docs papers BUT that is IF they PUBLISH or PRESENT. In that way, you can find out the doc's modus operendi and more so by just relying on words like 'smas' or 'deep plane'.

However, to understand it that way, I will tell you that one needs a lot of time to study anatomy and you need to go further than the anatomy they teach in school and that's IF one has ever taken those courses. For example, I'm well 'book learned' as to facial anatomy especially superficial movement muscles but still, there is lots of 'stuff' in the face that's not that simple simply because the anatomy in the books is actually attached to fascia sheaths that a surgeon learns to traverse. That's why something in the 'plane of the platysma' (smas plane) can CHANGE when you move away from it. It can be in the plane of some other fascia where other muscles are stuck too. That is WHY it is hard to describe what they are doing in 'planes' because the planes are NOT like mica planes. They are things that weave in and out of each other.

The Aston "FAME" technique is an example of a "plane" that is really not even describe in the anatomy books. Basically, it's some fascia attachment ('secret plane) found under the orbicularis or near there in which a finger can find it by feeling around and then it's a plane that's easily cut down. It's something where to find it, one has to FEEL for it. That's what I MEAN when I say, the 'planes' of anatomy are not really described well by the books we read on anatomy but are sometimes described by surgeons who go into the face and find these un described fascial attachments while they are dissecting the face. Aston, just fortuitously found this 'secret plane' and tells other docs how to move their fingers around to find it and how to feel for it.

I mean, I can understand the anatomy of the face when I look at books on it and all. But there is a part that is 'practical' meaning the part where you have to be inside the face with your hands in there to kinesthetically 'understand' and of course, the docs can do that but may not be that great in verbalizing to us what they find. Hence, the confusing terms. LOL.

Anyway, I add this because I'm good at explaining stuff to other patients. I hope a doc steps in to correct me if my explanation is wrong somewhere or to add on to it.
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Postby traci46 » Wed Nov 28, 2007 8:16 pm

This is all becomming too technical. Do we really go into all this technicality when seeking plastic surgery? For the layman it is quite deep. Go below and read Dr. Yang's simplified post re this matter and what you should seek.
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