Treatment of the Superficial Musculoaponeurotic System

The treatment of the SMAS is performed according to the surgical planning when the surgeon evaluates the degree of muscular flaccidity. Usually when the pla-tysma muscle is flabby one can see its border laterally and medially (Fig. 39.11).

After the tunnelization procedure the lateral border of the platysma is pulled using fine forceps with-

  1. 39.11 a-f. A 75-year-old patient presenting abundant surgery. d, e, f One year after rhytidoplasty with plication of wrinkles with skin and muscle flaccidity on the face and neck. the platysma laterally combined with lipoplasty. The medial The medial borders of the platysma are visible. a, b, c Before borders of the platysma were not sutured
  2. 39.11 a-f. A 75-year-old patient presenting abundant surgery. d, e, f One year after rhytidoplasty with plication of wrinkles with skin and muscle flaccidity on the face and neck. the platysma laterally combined with lipoplasty. The medial The medial borders of the platysma are visible. a, b, c Before borders of the platysma were not sutured

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Fig. 39.12 a, b. Lateral plication of the platysma muscle. a Peroperative photograph showing the plication. b Close-up showing forceps holding the lateral border of the platysma to be sutured by the plication procedure

out any undermining (Fig. 39.12). By traction the plastysma is lifted up and backward to be sutured to the aponeurosis of the sternocleido muscle posteriorly. On the face, in front of the ear, the fascia is grasped with small hooks and also pulled and overlapped so it can be sutured along a line that begins at the lower margin of the zygomatic arch and extends downward around the ear. We use clear or colorless slowly absorbable material with isolated stitches. If colored suture is used it may show through the final cutaneous flap on thin skin. After suture ,the soft tissue may be palpable as a bridge over the deeper structures.

We do not do any suture medially on the submental region because it may create a thick and fibrotic tissue which is ungraceful and hard, forming a bridge from the chin to the neck. Regarding the anatomy of the platysma, according to Cardoso de Castro's [9] descriptions, the medial borders have a significant distance between them. Even when the medial margin of

Fig. 39.13. Peroperative photographs showing the direction of traction of the skin flap of the left side of the face. a Two forceps hold the facial flap. Using Pitanguy's marker to

the platysma is visible owing to its projection on the skin, we do not perform any plication on the submental region (Fig. 39.11). We found that performing only the lateral suture with suspension of the platysma improves the whole area on each side of the neck with a natural and smooth result. The platysma flaps described by Skoog [27], Guerrerosantos [10] and others may present beautiful results, but our preference is for a single plication and suture to the aponeurosis laterally.

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