Introduction

The goal of all face-lift procedures is to provide a natural, long-lasting, and rejuvenated cosmetic result without any permanent adverse effects, such as facial nerve damage [1]. Facial esthetic surgery commonly aims to repair deepening of the nasolabial folds and midfacial soft tissue descent. There have been many attempts to address these age-related changes both surgically and nonsurgically [2]. A comprehensive understanding of the facial anatomy and different procedures is necessary to perform an effective face-lift surgery [3].

Mitz and Peyronie first described the deep layer of the superficial facial fascia and named it the “superficial musculo-aponeurotic system” (SMAS) [4]. Many surgeons believed that the results of a SMAS face-lift were long-lasting and outstanding for the neck but not as good for the melolabial fold region [1].

While different face-lift techniques have been described, there is still a trend towards limited operative time and less invasive procedures.

The minimal access cranial suspension (MACS) lift, from Tonnard and Verpaele, is a short scar rhytidectomy with vertical purse string suture suspension of the facial tissue [5]. This procedure reduces recovery time and morbidity, and results are as stable as most traditional face-lift techniques [6].

There are some studies comparing the results of different methods of face-lift surgeries [1, 7–9]. This study was designed to compare the average amounts of facial lifting between the SMAS plication and MACS lift procedures in nine cadavers.

Materials and Methods

Ethical Approval

This study was approved by the local ethics committee of Forensic Medicine Organization of the Islamic Republic of Iran, according to the certification from Iran University of Medical Sciences Research Council. All the Information of the cadavers will remain confidential.

Design

Between October and December 2010, thirty-six surgeries were done on nine fresh cadavers; two surgeries on each half of the cadaver faces. First, we did MACS on one side of the face and then SMAS plication on the same side. The same process was done for the other side of face that means finally we performed eighteen SMAS plications and eighteen MACS lifts.

Facial topography was done with the cadavers in the lying position. Three anatomical landmarks were defined on the cadaver faces: The junction of the Marionette lines with the border of the lower jaw, the crossing between the lateral edge of the lip with the midline of the pupil, and the angle of the lower jaw (Fig. 1). These landmarks were intentionally defined to place all components of each part, especially the nervous system, inside the incision areas. To evaluate the symmetry of the face, both methods of SMAS plication and MACS lift were performed on each side of the cadaver face to determine the average amount of skin lifting on each side.

Fig. 1
figure 1

Three defined anatomical landmarks: a The junction of the Marionette lines with the border of the lower jaw. b The crossing between the lateral edge of the lip with the midline of the pupil. c The angle of the lower jaw

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The results of lifting three defined anatomical landmarks on two sides of the face were compared separately between the two methods; for example, the average amount of lifting at the junction of the Marionette lines and the border of the lower jaw with SMAS in the right side was compared with the same result on the left side and also with the result of the MACS lift.

Esthetic results were evaluated by two independent and board-certified ENT surgeons in the operating room.

Method of Surgeries

First, we did a minimal incision from the root of the helix to the inferior part of the lobule in the vertical direction then we dissected the supra-SMAS plane to the anterior border of the parotid gland and inferiorly in the neck until we saw the platysma. After that, we extended the superior part of the incision transverse in the temporal fossa about two centimeters in the hairline and exposed the periosteum of the temporal bone (Fig. 2). Then we performed three classic types of sutures in the MACS lift on each side of the face and fixed them to the temporal periosteum in an upward direction (Fig. 3). After evaluation of three landmarks in the face, we opened each suture and then again, we performed SMAS plication. We extended the incision in the neck as modified for SMAS plication. Then we dissected the SMAS completely and plicated it with absorbable suture in lateral and upward directions (Fig. 4).

Fig. 2
figure 2

A minimal incision was done from the root of the helix to the inferior part of the lobule in a vertical direction (a, b). The supra-SMAS plane was dissected to the anterior border of the parotid gland and inferiorly in the neck (c, d)

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Fig. 3
figure 3

Three classic types of sutures in a MACS lift (a, b). Then we fixed them to the temporal periosteum in an upward direction and evaluated the three landmarks lifting (c, d)

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Fig. 4
figure 4

SMAS plication was performed on the same face-half extending the incision as modified for SMAS plication (a, b). The SMAS was dissected completely and plicated with absorbable suture in lateral and upward directions (c, d)

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Statistical Methods

The data analysis was done using SPSS software version 18 (SPSS Inc, Chicago, Illinois, USA). Because the sample size was small, a one-sample Kolmogorov–Smirnov (KS) test was used to find normal distribution of the data and Leven’s test was done for the evaluation of the equality of variances. We used a paired sample T test for parametric variables and Wilcoxon signed-rank test for non-parametric variables. P values less than 0.05 were considered as significant.

Results

Nine fresh cadavers entered the study with the mean age of 53.11 ± 6.71 (between 45 and 65 years). Seven (77.8 %) were males and two (22.2 %) were females.

The average age was 54 ± 6.90 for men and 50 ± 7.07 for women. The body mass indices of cadavers were in the range of 25–35.

The average amounts of skin and muscle lifting up and out in centimeter at any defined landmark were compared between the SMAS plication and MACS lift methods (Table 1 & 2). As shown in Table 1, the average amounts of lifting of the three defined anatomical landmarks up and out were significantly greater in SMAS plication compared with the MACS lift procedure (P values < 0.05). Table 2 shows that facial symmetry in each of the two methods was not significantly different between the two sides of the face. In other words, both SMAS and MACS procedures provided a parallel symmetry for each one of the three defined landmarks.

Table 1 Average amounts of skin lifting up and out in the vertical direction in SMAS plication and MACS lift methods for each landmark
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Table 2 Comparison between the average amounts of skin lifting up and out in the vertical direction in each half of the face with SMAS plication and MACS lift procedures
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Discussion and Conclusion

The common goal of all face-lift procedures is to provide a long-lasting, natural, balanced, rejuvenated esthetic result with few complications and minimal downtime [2]. The understanding of facial anatomy and its changes through aging has led to the development of progressively less invasive techniques, such as the MACS lift, to respond to these core concerns [10].

The MACS lift technique, a short scar face-lift, is a simple procedure for mediofacial aging. This procedure involves no lateral tension, and may be performed with the patient under local anesthesia in 2–2.5 h [11]. This technique, in the simple or extended variation, delivers a reproducible and natural rejuvenation of the face and neck with minimal morbidity and a quicker recovery [12]. It is effective, providing a high level of patient satisfaction due to esthetic results, combined with rapid recovery and return to normal activities [13]. The MACS lift has been described to correct sagging and laxity of the lower and middle third of the face. It does not, however, fully address the neck or the lateral periorbital area frequently needing rejuvenation in most patients. Another shortcoming of the minimal access cranial suspension lift technique is visible scarring anterior to the temporal hairline that usually occurs despite the suggested surgical maneuvers consisting of zigzag beveled incisions [14].

SMAS plication, on the other hand, represents a growth that seeks to balance procedural invasiveness with recovery time and esthetic outcomes [15]. SMAS plication, malar fat pad repositioning, and correct traction of facial tissues also showed satisfactory results. This technique is less aggressive than undermining of the SMAS and deep-plane techniques [16].

The platysma muscle, submuscular aponeurotic system, and galea are the continuous superficial cervical fascia encompassing the majority of face, and this superficial soft tissue envelope is poorly anchored to the face [17]. Modern face-lift techniques have benefited from shorter incisions, more limited dissection of the SMAS and platysma and limited skin elevation to shorten postoperative recovery time and reduce surgical risks for patients [2].

The understanding of facial anatomy and its changes through aging has led to the development of several different face-lift techniques. Facial aging is mainly due to gravity’s long-term effects on the superficial soft tissue envelope, with more subtle effects on the deeper structural compartments [17]. Gassner et al. studied 50 cadaveric heads bilaterally, to delineate the anatomic architecture of the melolabial fold with surrounding structures. In contrast to previous reports, the SMAS was not found to form an investing layer in the midface. The findings of this study may augment our understanding of the complex anatomy of the midface and melolabial fold [18]. The extreme interest in developing new surgical approaches for rhytidectomy has led to a more natural and youthful restoration of the face by together lifting forehead, midface, and lower face. This produces a more harmonious balance of the upper and lower portions of the face than was possible before the introduction of face-lifting techniques [19].

There are a few studies in the literature, comparing results between different methods [18]. Adamson and his colleagues compared SMAS plication and deep-plane face-lift (DPFL) methods to determine if there is any observable difference in the midface of the patients. They defined five areas on the face and neck including the malar eminence, melolabial fold, jowls, cervicomental angle, and anterior neck banding and reported a significantly better improvement in both the midface and the neck of patients who underwent DPFL in comparison to SMAS plication [7].

In contrast, the comparative study by Becker et al. reported higher scores in terms of esthetic results for SMAS plication compared with DPFL. However, DPFL scored slightly higher in patients older than 70 years [1].

Prado et al., however, compared the outcomes of lateral SMASectomy and MACS lift in eighty-two patients retrospectively and reported no significant differences in cosmetic results between the two techniques at 1-month and 2-year postoperative follow-up [9].

Our study was designed to evaluate the average amounts of face lifting between two different methods: SMAS plication and MACS lift. However, the excursion of skin through the face-lift procedure is not the only criterion for validation of the technique. On the other hand, working with cadavers may not be so common in face-lift studies, but performing four surgeries on one face is almost only possible in a cadaver model; however, we tried our best to perform surgeries on fresh and even warm cadavers. The cadaver model also has another important limiting factor, in the aspect of long-term follow-up.

We put some representative photographs, containing the procedures performed on cadavers. However, the face is a complex 3-dimensional structure with different contours even within an anatomic subunit, and assessment of results by a 2-dimensional photograph must be crude and inaccurate [20].

As a conclusion, we can say that the overall amounts of facial skin movement and manipulation by invasive SMAS plication were greater than that by the MACS lift procedure in our study. However, it does not justify ignoring the benefits of MACS lift in terms of less invasiveness and rapid recovery [13]. The keys to consistent results are the surgeon’s judgment and ability to individualize a treatment plan according to the patient’s needs. To obtain natural-appearing results, the surgeon must consider the morphological characteristics of the aging face.