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SMAS vs. Deep plane

Postby MissJ521@aol.com » Wed Nov 28, 2007 8:22 pm

Ya, I know. It IS pretty technical. But as I was explaining to Harri, that's why it's hard to really 'explain' to a lot of people what the difference between the techiniques is. To some, you can but one needs some anatomy under belt and even then the differences have to do with anatomy the doctors touch and feel rather than the anatomy we learn even if we learn it in courses.


traci46 wrote: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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Postby harri » Thu Nov 29, 2007 3:06 am

It may be too technical but I do think we have to understand the basic type of facelift we are being offerred to help us choose the right surgeon. And it's nice to know we have a surgeon who has the technical ability to do any lift so we can be sure he isn't offfering us the only lift he feels comfortable doing. If all you've got is a hammer everything starts to look like a nail.

It's true that each surgeon will do things his way with little tricks he has learned over the years and at the end of the day we're trying to decide which surgeon rather than which lift is best for us. But a lot of times their attitude is 'trust me I'm a surgeon' and they're not exactly forthcoming about the type of facelift they do. Patients come away from a consult with no clue what they are letting themselves in for.

But it's take it or leave kind of knowledge isn't it - if you don't want to know, don't read the thread!

Dr Yang and Dr Naderi are both using the word 'imbrication' but I think they are talking about different lifts.

It's not that complicated really.

Denenberg describes a smas plication lift. The LSL ladies often say this is what they got. The surgeons lifts the skin and folds up the smas.

Dr Yang has shown a really good pix of the smasectomy. Baker is the biggest proponent of this technique. He thinks lifts have gone too 'deep' and pleas for caution. The surgeon lifts up the skin and cuts a wedge vertically out of the smas.

Dr Naderi - well I would call that a standard or conventional smas lift and forget about the word imbrication. But that's just me :lol: The difference is that the surgeon lifts the skin but then also cuts under the smas (sub smas) to raise a separate flap. He thinks the scar tissue this causes means the lift will last longer.

Deep plane - I think this is really an extended smas. The same as Dr Naderi's but which goes further across towards the nose. So I wouldn't use the term deep plane at all because it's confusing.

Hamra is the other extreme to Baker and his composite lift is frightening :evil:

It's the fact that people don't grasp the basic differences that allows marketeers like the LSL people to snare their victims, sorry customers. We do have to appreciate that one smas lift is not the same as another so we can make an informed decision.
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Postby harri » Thu Nov 29, 2007 3:18 am

Ya, I know. It IS pretty technical. But as I was explaining to Harri, that's why it's hard to really 'explain' to a lot of people what the difference between the techiniques is. To some, you can but one needs some anatomy under belt and even then the differences have to do with anatomy the doctors touch and feel rather than the anatomy we learn even if we learn it in courses


Thanks for trying Miss J. :lol: I'm convinced that there is a way of writing a 'dummie's' guide to facelifts without the need to understand the anatomy but perhaps it can only be written by someone who does. The biggest thing we need is some nice clear diagrams. Why don't surgeons have a model head with zips and flaps so they could show us what they were going to do.

The original question was about smas v deep plane. I think if we change the question to smas v extended smas it becomes easier to explain.
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Postby harri » Thu Nov 29, 2007 3:35 am

Suekk if you use the forums to research particular surgeons you have to understand why there might only be happy patients.

As you say the unhappy ones may not always want to share their stories simply because they are unhappy but there are more sinister reasons than that.

Some US boards (not makemeheal) insist unhappy patients have to prove their stories with pix whereas happy patients may sing as loud as they like without any pix.

Some surgeons police the boards to ensure that all bad posts with no pix are removed. I've watched them go! A Beverly Hills rhinoplasty surgeon Dr N is always doing this.

A UK clinic tried to sue our board with the result we don't allow any posts, good or bad about their surgeons. We always say sorry we don't talk about them so people can draw their own conclusions. I think that's fair enough!

The other factor is that the happy patients band together in a fan club and drive the unhappy ones from the board.
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Postby harri » Thu Nov 29, 2007 4:07 am

My preferred Rhytidectomy (lower facelift or cheek-neck lift) is to do liposuction to the neck (this also starts the dissection plane) then dissect the mid-line neck skin followed by a plastysma-plasty to tighten the mid-line neck and achieve a nice cervico-mental angle. Then I dissect the skin behind and in front of the ears widely connecting the dissection plane to the midline neck. Then I lift a large healthy SMAS flap up to the point necessary to get the desired pull. That means sometimes I dissect to the Masseter or Zygomaticus and sometime I do not and sometimes I go beyond it. Its a bit different in each patient. Then I suture the SMAS superiorly and posteriorly in front of the ear and also behind the ear. This Bi-vector pull on the SMAS really delineates the jaw line nicely. ALL of the tension is on the SMAS. There is ZERO tension on the skin so there is no "fake pulled back tight" look. All of the incisions are hidden in the hair or in the ear or behind the ear. There are no visible scars and you can wear your hair back or up without fearing visible scars.


Miss J I just thought DR Naderi's description of his lift fitted that of a standard smas lift. i.e. a skin flap and a smas flap re-positioned separately.

Are you saying it doesn't?

He doesn't mention imbrication here and I just think it serves to confuse. I'm not sure we need to know, especially as Webster 'proved' imbrication was no better than plication.

If I had a piece of material I wanted to make smaller I understand I could do it by either making darts (ie folding/plication) or cutting out bits and joining the raw edges together like a seam (imbrication) but I'm not sure I really care how the surgeon does that. Isn't the main thing where I got that piece of material from?

ie have I just lifted the skin and am working on the smas in situ or have I dissected under the smas and am working on a free flap of smas.
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Postby atlanti » Thu Nov 29, 2007 5:08 am

Harri - reading Miss J's note has explained something else to me. My SMASectomy plus neck was also mentioned in passing as "deep plane" and this perhaps could be because of going under the under the SMAS to the plat. muscle for the neck lift - so perhaps terminology is not always for extended SMAS lift . What do you think? I think you are both incredibly well informed.
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Postby harri » Thu Nov 29, 2007 5:39 am

I'm not well-informed atlanti - I've just done a lot of googling to try and make sense of it. But I don't have any expertise and I only feel a need to understand things at a certain level. The Goldilocks level if you like to coin Dr Yangs term.

If you google modified Baker smasectomy you'll see BJ and Norman Waterhouse and Bulstode have written a book together. I think you'd have to buy it :lol:

I've decided i don't like the word deep plane. It's too confusing.
The complaint about Baker is tight faces and loose necks so maybe the modified version is to address that.

Dr Yang Explains blog has an excellent post about neck lifts and I would want to know which neck muscles have been lifted - the ones by the ears or the ones in the centre.
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Postby harri » Thu Nov 29, 2007 6:03 am

http://archfaci.ama-assn.org/cgi/reprint/8/3/186.pdf

This is an interesting read.

The authors did 3 different facelifts on the same people at the same time and measured how much extra skin they managed to remove with each method. I hope they got their consent for the experiment. We've no idea what surgeons do while we are asleep.

Dr Yang discussed this in one of his posts.

The methods seem to be

1. smas plication (no smas flap),
2. excision of a short j-shaped flap
3. finally the excision of the deep or extended flap.

In the first procedure, a simple plication was carried out without
excision of intervening SMAS fascia. This lift corresponds
to what is now commonly referred to as the short flap face-lift.
In the second procedure, a J-shaped portion of SMAS approximately
3 cm in width was excised extending from below the
earlobe to the zygomatic arch, followed by imbrication of the
SMAS fascia. This standard SMAS face-lift is the most commonly
performed face-lift technique.12 In the third procedure,
a modified deep-plane dissection was performed beginning at
the existing anterior cut edge of the SMAS. A sub-SMAS flap
was developed and carried out over the malar surface as described
by Hamra


My UK surgeon has visited Hamra and I think I got number 3 which he called the extended smas. So yes we can get confused about the planes (superficial, sub smas, deep or whatever) but basically isn't it to do with the size of the smas flap lifted (remember Dr Yang and his carpet).

Basically there is always a skin flap.

There isn't always a smas flap.

The smas flap can be small or large and bits of it may be deeper in places as the surgeon's switch planes but am I bothered? I really just want to understand how big the flap is, not that it's thicker (deeper) in places. And I think the bigger flap just goes further across towards the nose.

I do get (sort of) what you have been saying Miss J. Are there 3 types of flap, skin only, smas-only and skin+smas in one thick piece (Skoog/Hamra). :?: A bit like an orange, we can peel the skin, then the pith or we can get both together.

In the experiment above they say modified deep plane because they obviously already have 2 flaps, one skin, one smas and can only go 'composite' from that point on to get skin and smas together.

Is Dr Naderi doing the standard smas face lift?

Dr Yang's smas diagram seemed to be none of these - is that the smasectomy which is not evaluated here?

Hamra has gone on to do the composite lift but that's another beast altogether.
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Postby harri » Thu Nov 29, 2007 10:48 am

A newer, even more dependable facelift technique is called the bi-planar, extended SMAS technique, where the SMAS muscle layer is elevated as far as the deep plane facelift. The difference here is that the skin is separated from the SMAS so it can be smoothed more naturally and gently, while the SMAS muscle beneath is pulled tightly to give a natural, longer lasting result


This makes sense to me. It was from Pearlman's website.

extended smas bi-planar ie. 2 separate flaps skin and smas.

deep plane - skin and smas in one thick flap.

Of course, the surgeon could slip between the planes but I'm not after doing the lift myself. I just want to understand the differences at lay-level.

So which is the most popular in the US - deep plane or extended smas?

I'm just curious why people always ask to compare smas v deep plane. Doesn't anybody have the extended smas in the US?
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Postby harri » Thu Nov 29, 2007 12:11 pm

I understand the deep plane lift to be very similar to the composite lift (short skin flap, then dissection of the SMAS via an incision under the SMAS to lift a skin and SMAS flap


I think Miss J once said the extended smas had that extended scar into the temple which implies it has a longer skin flap than the deep plane lift.

Of course, the Hamra composite goes much further into the eye area.
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Postby MissJ521@aol.com » Thu Nov 29, 2007 6:18 pm

Harri,
The terms are confusing. Take the word "imbrication". That very word was popularized by Dr. Little who did "malar imbrication": The act of folding the cheek periosteum on to itself for added bulk to the cheek.

When Dr. Naderi used the same word; imbrication in relation to a face lift with some SMAS manipulated it, to the best of my understanding, he used the word; "imbrication" to mean some of the cut was UNDER the SMAS so that under area could also be lifted and snipped off near the ear side of the face. So there you had a terminology that applied to actually doing some 'deep plane' (because some of the dissection went under the SMAS) and also a smasectomy; cutting out part of the smas (near the ear part of face) when the term "imbrication" was used. This comparison was offered as a way to differentiate smas imbrication from smas plication where the smas is just sutured in darts to fold itself over itself on the way to the ear (instead of releasing some of it under itself and sliding up and snipping off excess.) Point being that it was not termed what it was; some dissection under the SMAS with some SMAS snipped off but rather 'smas imbrication'.

It is also not clear to me what the main difference is between imbrication and plication. Both mean folding the tissue over onto itself. Perhaps, imbrication refers to one main fold over and plication refers to a series of darting type fanning folds in a series. But it does get confusing when "imbrication" is used when smas is snipped off.

"Extended SMAS" also is not clearly defined--or I'm not clear myself on the exactness of it's meaning. To the best of my knowledge, it can mean 2 of the following things:

1: the SMAS is "extended" RELATIVE to the plane of the platysma (the platysma is in part of the SMAS). That is to say the SMAS dissection can be extended to include somewhat of a lift (diagonal) to the CHEEK area if one extends the INCISION closer toward the temple in a lower face lift. In this way the smas layer that does NOT include the platysma (but other muscles) can be manipulated and it could be called an "extended SMAS" as in extending MORE of the DISSECTION to include areas of the face which are NOT the lower face part of SMAS but rather adding some other areas to mid face that is part of smas but not in the plane of the platysma smas. That is what I meant when I referred to extending the incision of the smas to include more lifting areas.

2: The SMAS could also be 'extended' by dissecting the skin closer toward the NLF.

"Deep plane" usually refers to going under the SMAS as to lift the smas as one flap separately. However, one could still go under SOME of the smas, fold over a flap of it or cut off a part of it (near the ear) and call "smas imbrication". I believe that was what Naderi was describing. the 'raw edge' under the smas where it was dissected gives a good underlying surface area for the tissue to 'glue itself together' and hold up well. It's just that the dissection under the SMAS near the ear is too close to a NERVE so it's higher risk.

To be able to actually CUT off some of the SMAS, one would HAVE TO dissect under the smas. So, anything that has to do with folding a big flap of smas onto itself near the ear or cutting out a strip of smas ANYWHERE would involve some deep dissection under the smas.

Cutting under the SMAS forms a broad surface area of 'body glue' to hold the lift up so the moved planes stick together without depending on sutures to hold things up which could tear through the tissues.
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Read these lecture notes

Postby MillenniumFPS » Thu Nov 29, 2007 8:56 pm

Hi Miss J and Harri,

Read these lecture notes for residents of the University of Texas Medical Branch at Galveston (UTMB), although it does not describe the extended SMAS facelift which is a hybrid of the two, the SMAS facelift is the most common type of facelift performed, not extended SMAS.

TITLE: Rhytidectomy
SOURCE: Grand Rounds Presentation, UTMB, Dept. of Otolaryngology
DATE: September 4, 2006
RESIDENT PHYSICIAN: Jing Shen, MD
FACULTY PHYSICIAN: Francis B. Quinn, Jr., MD
SERIES EDITORS: Francis B. Quinn, Jr., MD and Matthew W. Ryan, MD


http://www.utmb.edu/otoref/Grnds/Rhytid ... 060904.htm

Key excerpts:
SMAS lift

This technique is still the most commonly used facelift technique today. ...

Several techniques are available for suspension of the underlying soft tissue of the face and neck. 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, while 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. Proponents of imbrication feel that plication results in SMAS redundancy which can cause subcutaneous irregularities. These have been found to be short lived, however. The placement of sutures and the vectors of tension are well agreed-upon. The first suture is applied at the jaw line and is anchored at the mastoid periosteum, or deep tissues in the pre-auricular area. The choice of suture varies; most surgeons use permanent, while others use a longer lasting absorbable such as vicryl. Several sutures are applied along each vector, and the horizontal mattress technique seems to hold the tissues best. The posterosuperior vector in the neck is then created with sutures in the platysma being tightened by the SCM fascia or mastoid periosteum. Flattening of the jowls is accomplished with the third vector, as the SMAS is pulled with a suture in the deep preauricular tissues.

Deep-plane rhytidectomy

Deep-plane rhytidectomy was presented by Hamra in 1990. The main goal of deep-plane lift was to improve the nasolabial fold area, which was not adequately addressed by the SMAS lift. Descent of the cheek fat is responsible for the increasing redundancy of the nasolabial fold with aging. In order to reposition the cheek fat, Hamra believes that the cheek fat has to be lifted from the zygomaticus major and minor muscles which it rests on. The deep-plane facelift flap consists of skin, subcutaneous tissue, cheek fat and platysma. Hamra described his techniques as following. The skin incision is the same as SMAS lift. He then performs a limited subcutaneous dissection approximately 2-3 cm in front of the tragus, ending at the jawline. The SMAS is incised with a scalpel and the dissection is developed with spreading scissors. The lower extend of the dissection is at the jawline, and the upper extent is at the malar eminence, where the vertical ligaments are divided. When the lateral edge of the zygomaticus major muscle is reached, the dissection then changes to the level superficial to the zygomaticus musculature. As the facial nerve innervates these muscles from the under surface, it is important to stay in a plane superficial to the zygomaticus muscles. The dissection exposes the orbicularis and zygomaticus muscles and extends media to the nasolabial fold.


Image
Plication (non-medical definition):
1. a. The act or process of folding.
b. The state of being folded.
2. A fold.


Image
Plication (medical definition):
1. the operation of taking tucks in a structure to shorten it.




Image
Image Credit: http://www.merriam-webster.com/dictionary/imbrication
Imbrication (non-medical definition):
    1 : an overlapping of edges (as of tiles or scales)
    2 : a decoration or pattern showing imbrication
[Latin imbrictus, covered with roof tiles, from imbrex, imbric-, roof tile, from imber, imbr-, rain.]

Imbrication (medical definition):
1. The operative overlapping of layers of tissue in the closure of wounds or the repair of defects.
2. to suture or sew (closure) together cut edges (wound edges) (My definition)
Multiple specialties ophthalmology, urology, general surgery, head and neck cancer surgery, all use imbrication in this manner.
Try googling imbrication + cut + edges: http://www.google.com/search?hl=en&rls= ... +cut+edges

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My online posts are not a substitute for a physician evaluation and examination and should not be considered as medical advice.

Private inquiries: info@nycface.com
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Postby MissJ521@aol.com » Thu Nov 29, 2007 9:13 pm

Thanks dr. Yang. I believe I read some of those texts before. But it always helps to review again.
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Postby harri » Fri Nov 30, 2007 2:28 pm

Funnily enough I had just read the bit about Webster too. My thought was how can work on dead people prove anything because there's no stress on the face as they're walking around.

But maybe I'm not thinking straight.

Well I know I'm not thinking straight :lol:
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Postby harri » Fri Nov 30, 2007 3:54 pm

The basic difference is that Denenberg is describing a superficial lift that stays on top of the smas whether he does a bit of imbrication or not. So is the smasectomy.

Dr Naderia is talking about raising a flap of smas.
Last edited by harri on Fri Nov 30, 2007 6:25 pm, edited 1 time in total.
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