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COSMETIC

Suture Suspension Malarplasty with SMASPlication and Modified SMASectomy: ASimplified Approach to Midface Lifting

R. Barrett Noone, M.D.

Philadelphia and Bryn Mawr, Pa.Background: The elements of midfacial aging include elongation of the lowereyelid, flattening of the malar eminence, hollowing in the submalar area, laxityof the jowls, and deepening of the nasolabial crease. Attention to rejuvenationof these areas has included various techniques involving movement of thesuperficial musculoaponeurotic system (SMAS) and elevation of the malar fatpad. A trend toward simplification in midface lifting has introduced the use ofsuspension sutures.Methods: This paper describes an approach to midfacial rejuvenation thatcombines the elements of SMAS plication and lateral SMASectomy with a suturesuspension of the malar fat pad to achieve long-lasting improvement of the agingmidface. The ptotic malar fat pad is suspended by suture to the deep temporalfascia. The suture passes from the subcutaneous position where it is fixed to themalar fat pad, through the SMAS, and over the periosteum of the zygoma, andis fixed to the deep temporal fascia. Plication of the SMAS over the suture,combined with lateral SMASectomy, provides three vectors of elevation beneaththe skin in midface rhytidectomy.Results: This technique was used in 259 patients between October of 2000 andOctober of 2004, producing effective long-lasting results with limited convales-cence and minimal complication rates.Conclusions: Safe dissection in the subcutaneous plane avoids injury to facialnerve branches. Plication of the SMAS with suture suspension of the malar fatpad avoids the prolonged convalescence and other morbidities of extensivesub-SMAS or deep plane dissections. This simplified approach can be quicklyand easily performed under local anesthesia as an isolated midface procedure,or can be combined with surgery of the forehead, eyebrows, eyelids, or neck bystandard techniques of rejuvenation. (Plast. Reconstr. Surg. 117: 792, 2006.)

The effects of the aging process on the softtissues of the midface include elongation ofthe lower eyelid, flattening of the malar

eminence, volumetric loss in the submalar areaof the cheek, prominence of the jowls, and deep-ening of the nasolabial fold. Since the descrip-tion of the superficial musculoaponeurotic sys-tem (SMAS) by Mitz and Peyronie in 1976,1surgical solutions for facial rejuvenation have

supplemented external incision, skin-tighteningrhytidectomies with direct procedures involvingthe SMAS. These range from simple plication toextensive composite rhytidectomies. Variationsin SMAS techniques have resulted in substantiallong-term correction of the above elements, withthe exception of the nasolabial crease. Recogni-tion of the malar fat pad as an entity distinctfrom the SMAS and intimately involved with theaging process at the nasolabial fold led to anevolution of techniques involving repositioningof the malar fat pad in combination with SMASprocedures. Although they produce excellent re-sults, many of these techniques require extensivedissection and have the potential for increasedmorbidity and prolonged convalescence. Thesearch for less extensive solutions to the problemhas introduced the concept of suspension su-tures in various forms for facial rejuvenation.

From the University of Pennsylvania School of Medicine, andthe Division of Plastic Surgery, Main Line Health Hospitals.Received for publication February 5, 2005; revised June 14,2005.Presented at the 73rd Annual Meeting of the AmericanSociety of Plastic Surgeons, Philadelphia, Pa., October 10,2004.Copyright ©2006 by the American Society of Plastic Surgeons

DOI: 10.1097/01.prs.0000209373.95115.70

www.plasreconsurg.org792

This article describes a simplified approach tomidface rhytidectomy that combines suture sus-pension of the malar fat pad with SMAS plicationand limited lateral SMASectomy. This techniquewas used in 259 patients in the 4-year periodbetween October of 2000 and October of 2004.

APPLIED ANATOMYIn the midface, the SMAS is a fascial layer

separating the subcutaneous fat from the fasciaenveloping the parotid gland, the mimetic mus-cles, and facial nerve branches. The SMAS is anextension of the superficial cervical fascia into theface and is continuous with the temporoparietalfascia in the temporal region. The SMAS is thickestover the parotid region and becomes thin in itsanterior extent over the malar region. The malarfat pad, a triangular subcutaneous structure basedat the nasolabial fold with its apex at the malareminence, lies superficial to the SMAS in the an-terior midface, and is considered part of the “fas-cial-fatty” layer of the face.2 Ligaments from theperiosteum of the zygoma run through the sub-cutaneous portion of the malar pad and insertdirectly into the dermis. Thus, the malar pad pro-vides fullness in the youthful midface. With aging,these fibrous septae relax, allowing ptosis of themalar fat pad and deepening of the nasolabialfold. Traction on the malar fat pad in a supero-oblique direction, along a line from the midpor-tion of the nasolabial crease to the junction of thezygoma and temporal bones, elevates the skin ofthe medial cheek and flattens the nasolabial fold.

An understanding of the anatomy of the tem-poral region is critical to this technique.3 TheSMAS extension (the temporoparietal fascia) in-vests the frontal (temporal) branch of the facialnerve (cranial VII) and the branches of the su-perficial temporal artery. This superficial fascia isseparated from the deep temporal fascia by looseareolar tissue. The deep temporal fascia covers thetemporalis muscle and splits to envelop the peri-osteum of the zygomatic arch. As will be described,the suture retriever is placed on the surface of thedeep temporal fascia and is directed through theloose areolar tissue in the prezygomatic space4

deep to the temporoparietal fascia and the tem-poral nerve branch.

The temporal branch crosses the zygomaticarch and innervates the frontalis, orbicularis oculi,and corrugator muscles. The zygomatic branchesextend to the lateral angle of the orbit and alsointo the orbicularis oculi. The buccal branches aredeep to the SMAS and are well away from anymaneuvers involved with the technique. The tem-

poral branch is well posterior to the point of pen-etration of the SMAS by the suture retriever. Thezygomatic branches are inferior and anterior tothis point, described by Mendelson as a surgical“safe space.”5

DESCRIPTION OF TECHNIQUESuture suspension malarplasty with SMAS pli-

cation may be performed as an isolated midfacelift procedure, or can be combined with otherfacial rejuvenative operations, including blepha-roplasty, brow lifting (open or endoscopic), andany procedure performed for rejuvenation of theneck. The location of incision depends on theextent of the operative procedure selected. Theconventional incision enters the temporal area ona line corresponding to the posterior aspect of theexternal auditory canal. Alternatively, a skin inci-sion may be made along the temporal hairline, butthe posterior aspect of such an incision must allowexposure to the deep temporal fascia. The incisionextends in the conventional face lift location intothe post auricular sulcus if only the midface isaddressed. If exposure for neck surgery is desired,posterior extension over the mastoid extendsalong a line directed posteriorly from the superioraspect of the external auditory canal. The skin flapis elevated in a subcutaneous plane to a pointconsistent with a line drawn perpendicular fromthe lateral canthus. The anterior extent of thisdissection is approximately 2 cm posterior to theoral commissure in the face. The integrity of theadherence of the malar fat pad to the skin lateralto the nasolabial fold is maintained. If neck sur-gery is combined, superficial dissection of the skincontinues inferior to the border of the mandibleto reach the submental incision. The superior ex-tent of the subcutaneous dissection extends to justbelow the orbital rim and over the superior borderof the zygoma. At this point, the subcutaneousdissection is superficial to the superficial temporalfascia and caudal to the hair-bearing skin of thetemple. The supra-auricular incision in the tem-poral area is carried deep to the superficial fasciato identify the deep temporal fascia. Dissection iscontinued in an anterior direction in this planeuntil the parietal branch of the superficial tem-poral artery is identified, suture ligated, and di-vided. Thus, a deep plane is entered between thesuperficial and deep temporal fascia. The extentof flap dissection in the plane immediately abovethe deep temporal fascia is dependent on the ex-tent of temporal scalp resection desired. Onlyminimal deep dissection anterior to the division ofthe artery is needed for exposure for the suture

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retriever. After dissection is complete, the malarfat pad is identified and elevated with the surgicalforceps along the line between the upper nasola-bial fold and the midzygoma. An estimate is madeof the amount of movement of the malar fat padand the contiguous anterior SMAS. Measurementsindicate that the malar fat pad can be advancedbetween 1.0 and 2.5 cm. When the maximum ex-cursion is judged with the surgical forceps, a fig-ure-of-eight suture of 2-0 monofilament polydiox-anone (taper SH needle; Ethicon, Somerville,N.J.) is placed in the substance of the malar fat padand its enveloping fascia (Fig. 1). Thin suture-passing instruments are available in all generaloperating rooms. The SNARE suture retrievermanufactured by Smith and Nephew (Andover,Mass.) is preferred. It is long and thin (externaldiameter, 2 mm) but sturdy enough to penetratethe SMAS. When opened, the wire loop at the tipallows easy entry of the suture. The suture retrieveris passed along the surface of the deep temporalfascia and over the periosteum of the zygoma at

the anterior third of the zygomatic arch. At thispoint, it penetrates the SMAS through the surgical“safe space.” The end of the suture retriever is thenin the subcutaneous position, with the handle atthe level of the deep temporal fascia (Fig. 1). Thepolydioxanone suture is passed through the wireloop of the suture retriever by way of the proximalneedle end and secondly by the distal free end ofthe suture. Both are passed through the aperturein the same direction. The needle is then cut fromthe proximal end and both ends of the suture arepulled along the track of the retriever to the deeptemporal fascia (Fig. 2). A free needle is then usedto secure one end of the polydioxanone sutureinto the deep temporal fascia. A surgeon’s knot isused to place the desired tension through thesuture to the malar fat pad to achieve the excur-sion determined by the initial measurement. Thesuture is then tied securely to the deep temporalfascia. The SMAS inferior and posterior to thesuture location in the fat pad is then plicated at thelower border of the zygoma with interrupted su-tures of 3-0 polydioxanone reinforced with a con-tinuous suture of 3-0 Vicryl (polyglactin 910, PS2needle; Ethicon). The imbrication of the anterioraspect of the malar fat pad conceals the suspen-sion suture and is usually performed with the su-ture that eventually completes the SMAS plication.This maneuver serves to create malar augmenta-tion as well as SMAS elevation. After plicationalong the fat pad and the zygomatic arch is com-pleted, strip SMASectomy is performed by resect-ing 2 to 3 cm of redundant SMAS, extending froma point just posterior to the SMAS plication toward

Fig. 1. After division of the parietal branch of the superficial tem-poral artery, a deep plane is entered between the superficial anddeep temporal fascia. A figure-of-8 suture of 2-0 polydioxanoneis placed in the substance of the malar fat pad and its envelopingfascia. The suture retriever is passed along the surface of the deeptemporal fascia, over the periosteum of the anterior third of thezygomatic arch, and through the SMAS, well anterior to the tem-poral branch of the facial nerve.

Fig. 2. Traction on the suture moves the malar fat pad between1 and 2.5 cm in a vertical-oblique direction. When the desiredposition of the fat pad is achieved, the suture is secured by a freeneedle to the deep temporal fascia.

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the earlobe and then into the neck along theanterior border of the sternocleidomastoid mus-cle (Fig. 3). Closure of the SMASectomy is alsocompleted using 3-0 polydioxanone suture and3-0 Vicryl (Fig. 4).

Cautery hemostasis is followed by skin excisionand closure. The skin tightening is directed in aline slightly more posterior than the obliquely di-rected malarplasty and the vertically directedSMAS plication. Skin excision, drains, closure,dressings, and postoperative care are at the dis-cretion of the surgeon, consistent with standardface lift techniques.

RESULTSAfter the addition of the suture suspension to

the author’s face lift technique, 259 patients un-derwent the procedure between October of 2000and October of 2004. The majority of the opera-tions were performed in combination with otherrejuvenative procedures of the face, especially

blepharoplasty and neck lift with platysma plica-tion. Endoscopic brow lifts were often combinedwith the midface procedure. In only 19 patientswas the midface procedure performed as an iso-lated entity. Although evaluation was subjective,in the 187 patients followed for more than 1 yearafter surgery, nasolabial fold improvement wasnoted when compared with previous subjectiveevaluation of SMAS plication without attentionto the malar fat pad. In the first 135 patients,nonabsorbable 3-0 Prolene was used for the su-ture suspension. Because two patients requiredremoval of the suture from the deep temporalfascia as a result of persistent palpability, includ-ing actual erosion of the skin by the suture inone patient, a transition was made in Septemberof 2002 to the use of 2-0 polydioxanone suture.In the subsequent 124 patients, no complica-tions related to this absorbable suture were en-countered. One patient complained of persis-tent headaches in the temporal regionassociated with trismus, but this resolved by thesixth postoperative week after treatment with anonsteroidal anti-inflammatory agent. Palpabil-ity of the polydioxanone sutures used in the

Fig. 3. The elevated SMAS is plicated at the lower border of thezygoma, with sutures placed in the fascia and not in the perios-teum. The plication sutures conceal the suspension suture andimbricate the SMAS and fat pad. Redundant SMAS (shown ingreen) is excised.

Fig. 4. The elevated SMAS, fat pad, and defect from the SMASec-tomy are closed as a unit.


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SMAS plication was often noted in the earlypostoperative period, with complete resolutionin all patients after 4 months. There were noinstances of muscle paresis secondary to facialnerve injury. Four patients (1.5 percent) re-

quired reoperation for evacuation of hemato-ma; all cases were associated with complete neckskin undermining and platysma surgery. One ofthe patients requiring hematoma evacuationand a second patient, a chronic smoker, devel-

Fig. 5. This 45-year-old woman illustrates the use of suture suspension malarplasty with SMASplication and redundant SMASectomy for midface lifting only. (Above) Preoperative and postop-erative frontal views. (Below) Oblique preoperative and 12-month postoperative views.


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oped preauricular skin necrosis. Both healedwith conservative treatment.

The low incidence of morbidity was accom-panied by rapid convalescence. With appropri-ate makeup techniques, most patients were ableto return to employment and social activities 2weeks after the midface lift combined with necklift and blepharoplasty procedures. When sub-

periosteal endoscopic brow lift was added, anadditional week of convalescence was expected.

All elements of midface aging were addressedwith this technique. As an isolated procedure, it isreserved for a relatively young person who doesnot need neck, eyelid, or brow surgery (Fig. 5).Suture suspension malarplasty with SMAS plica-tion can be combined with other procedures, such

Fig. 6. Suture suspension malarplasty with SMAS plication in the midface is combined with upperand lower blepharoplasty, platysmaplasty, and perioral carbon dioxide laser resurfacing. Frontaland lateral preoperative and postoperative views illustrate marked improvement in nasolabial foldappearance 18 months after surgery.


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as four-lid blepharoplasty, corset platysmaplasty,lateral platysma plication, and perioral carbon di-oxide laser resurfacing (Fig. 6). The lower eyelidcan be shortened with fat pad elevation and fix-ation (Fig. 7). The most effective result from theprocedure is seen with nasolabial fold improve-ment (Fig. 8).

Undermining of the skin over persistent malarmounds, with imbrication of the SMAS and thesuspended malar fat pad, can correct the malarmound deformity (Fig. 9). This same technique ofskin undermining and redraping with SSM andplication can be used to treat untoward results ofprimary or secondary aesthetic procedures (Fig.10).

DISCUSSIONAdvancement of the malar fat pad, the SMAS,

and the skin in different vectors gives a mechanicaladvantage during and after healing to produce thebest opportunity for improved long-term results.The supero-oblique direction of pull of the malarfat pad presents a vector perpendicular to thenasal labial fold. The second vector, in a verticaldirection, is a result of SMAS elevation by plicationand imbrication over the malar fat pad suture.Despite the anatomic fact that the malar fat pad issuperficial to the SMAS, the imbrication of theSMAS tissues in an anterior direction is extendedto an imbrication also of the malar fat tissues,producing even more malar augmentation. This

second vector overlaps the first and fixes the SMASand malar fat pad together in a higher verticaldirection, shortening the elongated lower eyelid.In addition, the volumetric improvement of thezygoma and anterior malar area is an attempt tosatisfy the concept popularized by Little that cre-ation of the Ogee curve to the face in oblique viewrestores a more youthful appearance.6,7 TheSMASectomy, which begins at the posterior aspectof malar plication sutures, essentially removes theredundant SMAS in a posterolateral direction,contributing to a smoother contour and providinga third vector fixation point, along with redrapingand excision of the skin. The malar fat pad and theenveloping overlying skin contribute to the mid-cheek mass, which must be elevated and fixed toprovide improvement at the nasolabial fold. Tight-ening the SMAS only, without attention to theoverlying cheek fat and the skin, may produce anactual deepening of the nasolabial fold ratherthan its flattening.

The suture suspension malarplasty–plicationtechnique combines some concepts introduced byothers into a simplified coordinated technique formidface rejuvenation.

SMAS PlicationAfter the SMAS was described,1 surgical at-

tempts to correct aging were directed toward tech-niques of tightening the SMAS.8–10 In the early1980s, I instituted SMAS plication into my face lifttechnique. After Baker introduced the concept oflateral SMASectomy in 1994,11 I added a modifi-cation of this technique to the plication method.Because the SMAS is elevated by the plicationmaneuver, the SMASectomy I describe is not theclassic technique of Baker. My technique servesonly to resect redundant SMAS. Hamra’s intro-duction of the deep plane rhytidectomy in 1990focused attention on an entirely new concept ofrejuvenation by composite repositioning of facialtissues.12 This very effective, but complicated, pro-cedure opened the possibilities of further mor-bidity in midface lifting. The prospective studythat compared lateral and standard SMAS face liftswith extended SMAS and composite rhytidecto-mies by Ivy, Lorenc, and Aston13 reinforced formany a renewed confidence in the simpler, saferapproach. These authors reinforced the contribu-tion by Webster et al.,14 who showed no differencebetween SMAS plication and SMAS underminingwith imbrication in face lifting. The use of SMASplication and later lateral SMASectomy producedfor me consistent reproducible results with jowl

Fig. 7. Fat pad elevation and fixation addresses the long lowereyelid, one of the common signs of midface aging. (Above) Pre-operative oblique view. (Below) View after suture suspension ofthe malar fat pad with midface lifting 16 months after surgery.


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elevation, midface fullness, and some malar aug-mentation. However, the results in long-term im-provement of the nasolabial fold were disappoint-ing, and attention to the cheek mass, consisting ofmalar fat and skin, was necessary.

Malar Fat Pad ElevationThe disharmony produced by SMAS techniques

alone, without addressing the anterior midface re-

lationships of the malar fat pad, the skin, and thenasolabial fold, gained attention in the 1990s. Moreeffective results were produced by combining verti-cal-vector orientation of the malar fat pad with theSMAS procedures. Owsley popularized this conceptby undermining beneath the fat pad and separatingit from the SMAS, keeping the fat pad attached tothe skin, and repositioning the fat pad by attachingit to the SMAS.15–17 This contribution demonstratedthe effectiveness of nasolabial fold improvement by

Fig. 8. Improvement of nasolabial fold appearance is demonstrated 1 year after surgery. (Left)Preoperative frontal and lateral views; (right) postoperative views.


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elevating the composite of malar fat and its attach-ments to the skin. However, similar to the deepplane dissections, Owsley’s technique required a dis-section above the SMAS-invested levator muscles.Because branches of the facial nerve in that regionlie deep to the SMAS, it was considered safe to sep-arate the fat pad from the underlying SMAS tissues.Careful dissection in this area is obviously required

and the potential for nerve injury could exist absentdetailed attention to dissection techniques. Othershave emphasized elevation of the malar fat pad with-out separating it from the underlying SMAS andthereby moving the SMAS along with the malar fatpad and skin to elevate and reposition the nasolabialfold as well as the commissure area of the mouth.18,19

The emphasis of these contributions on movement

Fig. 9. (Left) Malar mounds persisted after upper and lower blepharoplasty. (Right) After suturesuspension malarplasty and SMAS plication, improvement is illustrated in the appearance of themalar mounds 15 months after surgery.


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of the superficial tissues along with the anteriorSMAS is directed toward counteracting the ef-fects of gravity on the skin and subcutaneous

tissue by vertical elevation and fixation. Repo-sitioning the malar pad in deeper plane tech-niques results in more prolonged swelling and

Fig. 10. (Above, left) A malar deformity and tragal distortion persisted after subperiosteal amidface lift through the subciliary approach. The prior surgeon’s attempt at revision resultedin fibrosis and distortion of the infraorbital soft tissues. (Above, right) Frontal view after sub-cutaneous dissection, suture suspension of the malar fat pad, and SMAS plication, 20 monthsafter revision surgery. (Below, left and right) Left oblique preoperative and postoperative viewsof the above patient.


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delayed convalescence than do the simpler tech-niques of elevating the malar fat pad in con-junction with plication of the SMAS tissues.

Suture SuspensionThe technique described in this article com-

bines the elements of malar fat pad elevation withconcepts of suspension techniques in the midface.Yousif et al.20 use a polytetrafluoroethylene stripcut from a sheet of Mycro Mesh for suspension.Sasaki and Cohen21 approach the midface by usinga percutaneous cable suture. Another less com-plicated technique fixes a pursestring plication ofthe SMAS to the zygomatic bone.22

My technique is similar to other suspension tech-niques in that I keep the connections among the malarfat, the overlying skin, and the underlying SMAS, andin that suspension sutures are used to fix the fat pad.My technique differs in that the suture suspension isdone by passing the suture deep to the SMAS andfixing the suture to the deep temporal fascia, therebytotally eliminating the suture from the subcutaneousposition. DeCordier et al.19 suspend the fat pad bysutures in the subcutaneous position to the superficialtemporal fascia at the level of the lateral eyebrow. Al-though they do not notice palpability or visibility of thesuture in the subcutaneous tissue, this is a concern Iavoid by keeping the suspension suture deep in thefacial tissues by passing it through the SMAS, over theperiosteum of the zygoma, and fixing it to the deeptemporal fascia. Since the change in suture materialmidway through the above-described patient series, noneed for suture removal because of exposure or pal-pability has been seen.

Data supplied by Ethicon indicate that absorp-tion of the polydioxanone suture is minimal untilabout the 90th postimplantation day, allowing am-ple time for collagen synthesis, adherence of thetissues by fibrosis, and development of tensilestrength.23 Absorption of the suture is essentiallycomplete within 6 months.

CONCLUSIONSEffective rejuvenation of the midface can be

achieved by a safe, simplified approach combining su-ture suspension of the malar fat pad with lateral mod-ified SMASectomy and SMAS plication. A safe dissec-tion in the subcutaneous plane avoids injury to facialnerve branches. Plication of the SMAS with suture sus-pension of the malar fat pad avoids the prolongedconvalescence and other morbidities of extensive sub-SMAS or deep plane dissections. This simplified ap-proach can quickly and easily be performed underlocal anesthesia as an isolated midface procedure, or it

can be combined with rejuvenation of the forehead,eyebrow, eyelids, and neck by adding other conven-tional techniques of facial rejuvenation. Since Octoberof 2000, the technique has been used in 259 patients,with effective results and minimal morbidity. Satisfac-tory improvement was noted in flattening of the naso-labial fold, augmentation of the malar area, elevationof the jowls, shortening of the lower eyelid, and resto-ration of volume to the midcheek.

R. Barrett Noone, M.D.888 Glenbrook Avenue

Bryn Mawr, Pa. [email protected]

ACKNOWLEDGMENTSThe author acknowledges the assistance of Lisa B.

Cassileth, M.D., and Robert K. Lowry, P.A.C., both ofwhom provided advice in the early development of thistechnique.

REFERENCES1. Mitz, N., and Peyronie, M. The superficial musculoaponeu-

rotic system (SMAS) in the parotid and cheek area. Plast.Reconstr. Surg. 58: 80, 1976.

2. Yousif, N. J., and Mendelson, B. C. Anatomy of the midface.Clin. Plast. Surg. 22: 227, 1995.

3. Stuzin, J. M., Baker, T. J., and Gordon, H. L. The relationshipof the superficial and deep facial fascia: Relevance to rhyti-dectomy and aging. Plast. Reconstr. Surg. 89: 441, 1992.

4. Mendelson, B. C., Muzaffar, A. R., and Adams, W. P. Surgicalanatomy of the midcheek and malar mounds. Plast. Reconstr.Surg. 110: 885, 2002.

5. Mendelson, B. C. Extended sub-SMAS dissection and cheekelevation. Clin. Plast. Surg. 22: 325, 1995.

6. Little, J. W. Volumetric perceptions in midfacial aging withaltered priorities for rejuvenation. Plast. Reconstr. Surg. 105:252, 2000.

7. Little, J. W. Three-dimensional rejuvenation of the midface:volumetric resculpture by malar imbrication. Plast. Reconstr.Surg. 105: 267, 2000.

8. Rees, T. D., and Aston, S. J. A clinical evaluation of the resultsof submusculoaponeurotic dissection and fixation infacelifts. Plast. Reconstr. Surg. 60: 851, 1977.

9. Adamson, J. E., and Toksu, A. E. Progress in rhytidectomy byplatysma-SMAS rotation and elevation. Plast. Reconstr. Surg.68: 23, 1981.

10. Aston, S. J. Platysma-SMAS cervical facial rhytidectomy. Clin.Plast. Surg. 10: 507, 1983.

11. Baker, D. C. Lateral SMASectomy: A new, safer approach torhytidectomy. Presented at the Annual Meeting of the Amer-ican Society for Aesthetic Plastic Surgery, Dallas, Texas, 1994.

12. Hamra, S. T. The deep plane rhytidectomy. Plast. Reconstr.Surg. 86: 53, 1990.

13. Ivy, E. J., Lorenc, Z. P., and Aston, S. J. Is there a difference?A prospective study comparing lateral and standard SMASfacelifts with extended SMAS and composite rhytidectomies.Plast. Reconstr. Surg. 98: 1135, 1996.

14. Webster, R. C., Smith, R. C., Papsideo, M. J., et al. Compar-ison of SMAS plication with SMAS imbrication in facelifting.Laryngoscope 92: 901, 1982.


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15. Owsley, J. Q. Lifting the malar fat pad for correction ofprominent nasolabial folds. Plast. Reconstr. Surg. 91: 463,1993.

16. Owsley, J. Q., and Fiala, T. G. Update lifting the malar fat padfor correction of prominent nasolabial folds. Plast. Reconstr.Surg. 100: 715, 1997.

17. Owsley, J. Q. Lifting the malar fat pad for correction ofprominent nasolabial folds. Aesthetic Surg. J. 19: 153, 1999.

18. Robbins, L. B., Brothers, D. B., and Marshall, D. M. AnteriorSMAS plication for the treatment of prominent nasoman-dibular folds and restoration of nasal cheek contour. Plast.Reconstr. Surg. 96: 1279, 1995.

19. DeCordier, B. C., de la Torre, J. I., Al-Hakeem, M. S., etal. Rejuvenation of the midface by elevating the malar fatpad:

Review of technique, cases and complications. Plast. Re-constr. Surg. 110: 1526, 2002.

20. Yousif, N. J., Matloub, H., and Summers, A. N. The midfacesling: A new technique to rejuvenate the midface. Plast. Re-constr. Surg. 110: 1541, 2002.

21. Sasaki, G. H., and Cohen, A. T. Meloplication of the malarfat pads by percutaneous cable suture technique for midfacerejuvenation: Outcome study (392 cases, six years experi-ence). Plast. Reconstr. Surg. 110: 635, 2002.

22. Saylan, Z. Purse string-formed plication of the SMAS withfixation to the zygomatic bone. Plast. Reconstr. Surg. 110: 667,2002.

23. Ethicon. PDS II (polydioxanone) suture. Information forHealth Professionals. Available at http://www.ethicon.com.Accessed February 1, 2005.


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