The superficial musculoaponeurotic system graft is harvested as a single piece of tissue by firm traction on the tissue and careful use of the rhytidectomy scissors. The surgeon must stay superficial to the parotid fascia and great auricular nerve during this maneuver.
A typical superficial musculoaponeurotic system graft after harvesting during rhytidectomy.
Preparation for implantation of the superficial musculoaponeurotic system graft into the nasolabial fold. A, Creation of a subcutaneous tunnel from the nasal vestibule to the stab incision at the inferior aspect of the nasolabial fold using a small hemostat. B, Insertion of the tendon-pulling forceps (Anthony Products Inc, Indianapolis, Indiana) from the inferior aspect of the tunnel, with tips exiting via the nasal vestibule.
Curved tendon-pulling forceps (Anthony Products Inc, Indianapolis, Indiana).
Completion of the superficial musculoaponeurotic system (SMAS) graft implantation procedure. A, Introduction of the SMAS graft into the nasolabial fold via the nasal vestibule incision. B, Gentle traction on the leading edge of the SMAS graft by the tendon-pulling forceps (Anthony Products Inc, Indianapolis, Indiana) allows for positioning of the SMAS into the subcutaneous pocket created just deep to the nasolabial fold.
A patient from the treatment group who underwent a mini–face-lift, endoscopic forehead-lift, upper and lower blepharoplasty, laser skin resurfacing of the perioral region, and superficial musculoaponeurotic system graft implantation to the nasolabial folds and upper lip. Preoperative (A-C) and 1-year postoperative (D-F) photographs are shown from left oblique (A and D), frontal (B and E), and right oblique (C and F) views.
A patient from the treatment group who underwent a regular face-lift, endoscopic forehead-lift, laser skin resurfacing of the perioral region, and superficial musculoaponeurotic system graft implantation to the nasolabial folds and upper lip. Preoperative (A-C) and 1-year postoperative (D-F) photographs are shown from left oblique (A and D), frontal (B and E), and right oblique (C and F) views.
A patient from the control group who underwent a regular face-lift with endoscopic forehead-lift, upper and lower blepharoplasty, and a rhinoplasty. Preoperative (A-C) and 1-year postoperative (D-F) photographs are shown from left oblique (A and D), frontal (B and E), and right oblique (C and F) views.
Moody MW, Dozier TS, Garza RF, Bowman MK, Rousso DE. Autologous Superficial Musculoaponeurotic System Graft as Implantable Filler in Nasolabial Fold Correction. Arch Facial Plast Surg. 2008;10(4):260-266. doi:10.1001/archfaci.10.4.260
To determine whether superficial musculoaponeurotic system (SMAS) graft implantation can improve the appearance of the nasolabial fold.
Single-blinded cohort study in a private facial plastic surgery practice. Treatment and control patients were selected from those presenting for aesthetic surgery. All patients underwent rhytidectomy with SMAS imbrication by a single surgeon. In addition, treatment patients underwent subcutaneous implantation of excised SMAS strips to the nasolabial fold. Treatment and control patients were matched for any other simultaneous procedures known to affect appearance of the nasolabial folds. Preoperative and postoperative photographs were graded by 3 blinded observers using the Wrinkle Severity Rating Scale to evaluate the nasolabial fold. Postoperative photographs were evaluated approximately 3 months and again 1 year after the procedure.
Compared with controls, there was a significant difference in the nasolabial folds of patients undergoing SMAS implantation at the 3-month postoperative evaluation (P = .03; χ2 = 4.696). This benefit was lost when the results were evaluated 1 year after the procedure (P = .88; χ2 = 0.0212).
Superficial musculoaponeurotic system implantation to the nasolabial folds offers modest temporary improvement to this area in patients undergoing rhytidectomy with SMAS imbrication.
Correction of the nasolabial fold is a difficult problem facing the aesthetic surgeon if evidenced by nothing more than the myriad of methods available to address this issue. Face-lift methods including superficial musculoaponeurotic system (SMAS) fixation,1 deep plane techniques,2,3 and composite plane elevation4 all have attempted to produce a straightforward and reliable way to reduce prominence of the nasolabial fold, which is often associated with an aged and undesirable appearance.5 Excision of the nasolabial fold has been described,6 as has fat sculpturing,7 direct undermining,8 and liposuction.9 More recently, a multimillion dollar industry in the form of synthetic injectable implant materials has emerged, claiming to provide a quick and relatively noninvasive means of reducing this particular facial fold.10- 13 Unfortunately, these corrections are temporary at best.12,13Autologous tissue remains in many ways the most desirable implant.14 However, fascial and fat grafts have met with varying success, largely owing to the unpredictable resorption of these materials and the morbidity associated with a distant donor site.15,16
With this in mind, the senior author (D.E.R.) has used autologous SMAS as an implantable filler for correction of the nasolabial fold. Frequently, patients desiring correction of the nasolabial fold also desire facial rejuvenation surgery. Subsequently, many of these patients are excellent candidates for a traditional SMAS rhytidectomy, which also provides a tissue graft in the form of the excised SMAS. Rather than discarding this fibrofatty tissue, the surgeon can implant it subcutaneously beneath the nasolabial fold as a single solid strip. Although a similar procedure has been described recently,17 the efficacy of SMAS implantation in reducing the prominence of the nasolabial fold is described herein, to our knowledge, for the first time.
Correction of the nasolabial fold using autologous SMAS implantation begins with the typical rhytidectomy incision and undermining into the cervical region that allows for full visualization of the SMAS tissue overlying the parotid fascia. With the use of a forceps, the SMAS tissue just inferior to the zygomatic arch is firmly grasped and tented up as much as the tissue laxity will allow. A strip of SMAS tissue is then excised in a single strip using the rhytidectomy scissors and moving from the superior to the inferior fields. Care is taken to stay in the region superficial to the parotid fascia (Figure 1). This cut is then extended inferiorly toward the cervical region, curved posteriorly just anterior and inferior to the lobule of the pinna, and completed where it overlies the fascia of the sternocleidomastoid muscle. The great auricular nerve remains deep to the dissection, and the SMAS is harvested as a single piece of tissue while the SMAS imbrication is performed (Figure 2). The SMAS is stored in saline-soaked gauze on the back instrument table while the remainder of the rhytidectomy is completed.
Depending on the amount of SMAS harvested, this tissue can be trimmed to size depending on the length of the patient's nasolabial fold and the desired level of correction. At greatest length, it should be no longer than the nasolabial fold, and there is typically abundant SMAS available for each nasolabial fold that needs correction. A typical SMAS graft of acceptable size is approximately 5 × 1 cm.
The vibrissae of the nasal vestibule are then trimmed on each side. The patient's nasal vestibule and nasolabial fold are injected with 1 to 2 mL of a mixture of 2% lidocaine hydrochloride and epinephrine bitartrate (ratio, 1:100 000) using a 27-gauge needle. Stab incisions are then made just inside the nasal vestibule and at the inferiormost aspect of the nasolabial fold using a No. 15 blade. A small hemostat is then inserted into the stab incision at the nasal vestibule and, using small spreading motions, tunneled toward the inferior aspect of the nasolabial fold in a subcutaneous plane just beneath the dermis (Figure 3A). The tips of the hemostat should be visualized coming through the inferior incision to ensure complete creation of the subcutaneous tunnel. A small curved tendon-pulling forceps (Anthony Products Inc, Indianapolis, Indiana) is then introduced in a retrograde fashion through the inferior incision and passed superiorly until it exits at the incision created at the nasal vestibule (Figure 3B and Figure 4). The previously trimmed SMAS is grasped at the leading edge by the tendon-pulling forceps and at the trailing end by tissue forceps for improved control (Figure 5A). The SMAS strip is then advanced into the subcutaneous nasolabial fold pocket with gentle traction from the tendon-pulling forceps on the leading edge, moving from the superior to the inferior fields (Figure 5B). The trailing end of the SMAS is held in the tissue forceps to ensure that the SMAS is not advanced too far inferiorly.
Ideally, the ends of the SMAS are just visible at each of the incisions when the implant is in the proper position. The cheek can then be lifted slightly away from the dentition using the forefinger placed transorally to allow the ends of the SMAS to retract into the pocket fully. Alternatively, the ends can simply be trimmed. The incisions at the vestibule are then closed using 1 or 2 simple, interrupted, 5-0 plain catgut sutures. Those at the inferior aspect of the nasolabial fold are closed with a single 6-0 fast-absorbing gut suture. Antibiotic ointment is applied to the incisions. The remainder of the care for this procedure is identical to that for a standard rhytidectomy. The nasolabial fold should be only slightly overcorrected to avoid any obvious bulge in the early postoperative period.
To evaluate the efficacy of this procedure, we conceived a single-blind cohort study involving patients who had already undergone their procedures. The setting was the private facial plastic and reconstructive surgery practice of the senior author (D.E.R.), and the patients were identified from the medical records of those who had presented for cosmetic surgery to address the appearance of facial rhytids. Patients and their surgeon decided preoperatively which procedures they wished to pursue without regard to study criteria, and written informed consent was obtained for all procedures performed. Patients eligible for the treatment cohort included only those who had undergone primary SMAS imbrication rhytidectomy and autologous implantation of SMAS to their nasolabial folds bilaterally. Thirty-three patients were initially identified and, of these, 17 had preoperative and adequate postoperative photographs. Adequate postoperative photography was defined as availability of the 5 standard facial views (left lateral, left oblique, frontal, right oblique, and right lateral views) approximately 3 months and again 1 year after the patient's rhytidectomy. Photographic documentation of each patient was obtained on a digital camera (Sony DSC- D770; Sony Corporation, Tokyo, Japan) and, with the exception of intraoperative images, all photographs were obtained in the same room with standardized lighting and background. Patient photographs were not reviewed for efficacy of the procedure at that time. All patients who met the procedural criteria and who had adequate photographic documentation were included, with the exception of 1 patient who had undergone hyaluronic acid injection to her nasolabial folds during the study interval. Thus, 16 patients in the treatment cohort each underwent bilateral SMAS implantation to the nasolabial fold for a total of 32 treated nasolabial folds.
The medical records of the treatment cohort patients were then reviewed to determine the exact procedures performed at the time of surgery and any additional procedures performed during the follow-up period. Demographic information including age and sex was recorded, as was any postoperative complication, including injury to the facial nerve. Particular attention was paid to procedures that might affect the appearance of the nasolabial fold, including any form of skin resurfacing, submalar implants, chin implants, and the type of face-lift performed. The exact dates of the preoperative and postoperative photographs were also recorded.
The control cohort of 16 patients was created from patients who had also undergone primary nonrevision SMAS imbrication rhytidectomy but who had not received autologous SMAS implantation to the nasolabial folds on either side. Patients were excluded from serving as controls if they had undergone any injectable nasolabial fold correction during the follow-up period and if they lacked adequate photodocumentation. Patients were matched to treatment cohort patients on the basis of the other simultaneous procedures performed, with particular attention paid to those procedures known to alter the appearance of the nasolabial fold. Again, photographs were not reviewed for efficacy at that time, only for availability of the 5 standard facial views. No patient was excluded from serving as a control if they met appropriate procedural and photographic criteria, and the first 16 patients who met the criteria and could be matched to treatment cohort patients were used. The medical records of these 16 control cohort patients were then reviewed, and the same information was gathered as for the treatment cohort.
Photographic data from both cohorts were compiled into a single database. Each of the 32 patients had 3 sets of the 5 standard facial views entered into the database, representing preoperative and 3-month and 1-year follow-up photographs. Thus, a total of 96 sets of photographs were compiled, stripped of any identifying date and time information, and randomized. The photographic data were then given to each of 3 blinded observers (T.S.D., R.F.G., and M.K.B.) for the purpose of evaluating the right and left nasolabial folds in each photograph set. The blinded graders were unaware of when each photograph set was taken and which procedures the patient had undergone.
From the photographs, the left and right nasolabial folds were graded independently using the Wrinkle Severity Rating Scale (WSRS)18 (Table 1). The WSRS was chosen as the best published and validated means of rating the nasolabial folds.18- 20 The WSRS is a 5-point grading scale that describes the severity of the nasolabial folds. It has been shown to be a valid instrument with good intraobserver and interobserver reliability and was developed with the intention of creating a means to analyze the nasolabial folds objectively.
The graders viewed each photograph at an actual size of at least 6 inches in the greatest dimension, and each photograph was viewed at least twice. Magnification of photographs was permitted. The computer monitor used for viewing was appropriately adjusted for contrast and color before any grading was completed. Each photograph set of the 5 standard views was evaluated as a group, and each nasolabial fold was graded independently using the WSRS. Photograph graders were asked to note any problems or inadequacies with the photography. In addition, the grader warmed up by grading the photograph sets numbered 10, 20, 30, 40, 50, 60, 70, 80, and 90 before evaluating all of the sets in order from 1 to 96. This warm-up helped to familiarize the grader with the WSRS. The grades given during the warm-up were then discarded and not included in the analyzed data. Sample photographs from several individual patients taking part in the study are seen in Figures 6, 7, and 8.
Evaluation data from the 3 blinded observers were compiled and analyzed. We used the unpaired t test to compare the ages and preoperative nasolabial fold scores of the 2 cohorts. The Kolmogorov-Smirnov test was performed to determine whether the data differed significantly from the expected normal distribution. We calculated Pearson correlation coefficients to ensure that minor variations in the time between when a patient's individual photographs were taken and when his or her procedures were performed did not affect the results.
The WSRS scores from each grader were then used to calculate whether each patient showed improvement at each of the follow-up intervals. Contingency tables and the χ2 test were used to evaluate the differences in improvement between the 2 cohorts. For the sake of the contingency tables and the χ2 test, each nasolabial fold was treated as a separate procedure, and the results from each grader were treated as independent samples. We calculated Cohen κ coefficients between the individual graders to confirm interrater reliability.
Finally, all treatment and control cohort patients underwent evaluation together using the 1-sample t test. This test determines whether the study population as a whole demonstrated any significant change in the nasolabial fold score, regardless of whether the SMAS implantation procedure was performed.
Comparisons of the basic demographic data as well as the time from the procedures to the photography are shown in Table 2. There was no statistical difference in the average age of the 2 cohorts (P = .30; unpaired t30 = 1.058) or the average preoperative nasolabial fold scores (P = .28; unpaired t62 = 1.084). Thus, the 2 cohorts appeared well matched initially, and the normal distribution of changes in the nasolabial fold scores was confirmed at the first and second follow-up intervals (P > .10 and P = .08, respectively, Kolmogorov-Smirnov test). Calculated Pearson correlation coefficients showed that there was no significant correlation between the changes in a patient's individual nasolabial fold scores and the exact time interval at which that patient's photographs were taken. This was true for photograph sets taken during the 3-month follow-up visit (P = .60; F1,62 = 0.282) and those taken during the 1-year follow-up visit (P = .36; F1,62 = 0.842). Therefore, the changes in a patient's nasolabial fold scores were not merely due to when their photographs were taken. As a result, changes in the nasolabial folds must be attributed to the procedures performed.
The procedures undergone by the 2 groups are compared in Table 3. This includes all procedures and treatments between the time when the patient's set of preoperative photographs was taken and when the second set of postoperative photographs was taken. All patients underwent primary rhytidectomies, and no patient underwent any interval treatment during the study period that might affect their nasolabial folds except as noted in Table 3. Moreover, no patient in either cohort received any injectable fillers to the nasolabial fold during the study. Multiple patients in each group had undergone some sort of other facial surgery before their preoperative photographs were taken. However, almost all of these procedures were limited to the upper third of the face (eg, blepharoplasty or brow-lift), and none of these were thought to be able to affect the appearance of the nasolabial fold for the purposes of this study. For example, a few patients had undergone chemical peels several years before their rhytidectomies, whereas others had undergone previous rhinoplasty or hair transplantation.
At the 3-month follow-up, comparison of the treatment and control groups by means of the χ2 test revealed that there was a significant difference (P = .03; χ2 = 4.696). The odds ratio between the treatment and control groups was 1.96 (95% confidence interval, 1.105-3.486). The average nasolabial fold score of the treatment group fell from 2.86 preoperatively to 2.23 postoperatively (mean [SEM] change, 0.635 [0.108]). In the control group, the mean (SEM) decline in WSRS score was only 0.375 (0.0907), reflecting a change from 3.08 preoperatively to 2.71.
At the 12-month follow-up interval, comparison of the treatment and control groups by means of the χ2 test did not reveal a significant difference, however (P = .88; χ2 = 0.0212). The odds ratio between the treatment and control groups at 12 months was 1.00 (95% confidence interval, 0.5653-1.769). The average nasolabial fold score of the treatment group fell from 2.86 preoperatively to 2.44 postoperatively (mean [SEM] change, 0.427 [0.0973]). In the control group, the mean decline of the score was 0.479 (0.0819), reflecting a change from 3.08 preoperatively to 2.60. Thus, although there was a difference between the 2 groups at the first follow-up visit, this difference was lost by the time the 12-month follow-up photographs were taken.
The Cohen κ coefficients confirmed fair intergrader reliability between all graders. Each grader was individually compared with each other grader, and the κ coefficients were 0.320, 0.214, and 0.266. In addition, when treatment and control patients were analyzed together as a single group, regardless of whether SMAS implantation to the nasolabial fold was performed, the average improvement in the nasolabial fold score was 0.505 (0.0720). This was statistically significant (P < .001; 1-sample t63 = 7.019).
Complications between the 2 groups were similar. Three patients in the treatment group experienced temporary facial weakness involving the frontal branch of the facial nerve, whereas only 1 patient in the control group did. There was no other facial paresis of any sort, and all facial weaknesses were followed up to full resolution. No permanent facial paralysis occurred in either group. There was 1 hematoma in the treatment group vs 4 in the control group, and 3 of the control group hematomas required open drainage. The remainder were managed by means of needle aspiration, as were the 4 seromas in the treatment group and the 2 seromas in the control group. None of the hematomas or seromas in either cohort were in the region of the nasolabial fold. One patient in each group experienced earlobe detachment, and 9 patients from each group required some form of triamcinolone acetonide injection (Kenalog; Bristol-Myers Squibb, New York, New York) to modify the postoperative healing and scarring process.
Correction of the nasolabial fold remains a vexing problem for the facial plastic and reconstructive surgeon. Although SMAS implantation to this area is an attractive procedure for many reasons, no doubt the search will continue for an ideal long-lasting treatment.
Our data demonstrate that SMAS implantation offers good short-term improvement in the nasolabial fold. All patients included in the study showed approximately a 0.5-point improvement in their WSRS score at the 1-year follow-up, and this is likely owing to the SMAS imbrication rhytidectomy. For those patients desiring additional correction, however, SMAS implantation is an option, and it is durable for about 3 to 12 months. Increasing the amount of augmentation could potentially improve the long-term results, and this may be a topic for future investigation.
The reason for deterioration of the results over time is unclear. It may be that the implanted SMAS tissue simply resorbs or that the initial results are due more to prolonged edema than to true tissue augmentation. Perhaps the intrinsic anatomy and dynamic nature of this particular fold make it difficult to obtain satisfactory long-term results. Indeed, SMAS implantation offers temporary improvement to the area, as do a number of synthetic injectable fillers, but so far none of these agents can permanently eradicate this fold. The mimetic facial musculature seems relentless in its efforts to accentuate this wrinkle over time, and likely few would agree to paralysis of this expressive portion of the face for cosmetic improvement of the nasolabial fold alone.
Although further prospective studies would be useful to evaluate its full potential, the SMAS implantation procedure is safe, quick, and easy to perform, and there is no risk of allergic reaction. Furthermore, the SMAS itself is typically available in abundance at any primary rhytidectomy, and this procedure adds little additional cost other than operating time. For the nonsurgical patient, hyaluronic acid and other injectables will likely remain the material of choice. However, for those already undergoing a SMAS imbrication rhytidectomy, SMAS implantation offers temporary improvement to the nasolabial fold for only a minimal investment of the surgeon's and the patient's time.
Correspondence: Marcus W. Moody, MD, Rousso Facial Plastic Surgery, 2700 Hwy 280, Ste 300W, Birmingham, AL 35223.
Accepted for Publication: January 1, 2008.
Author Contributions:Study concept and design: Moody, Dozier, and Rousso. Acquisition of data: Moody, Dozier, Bowman, and Rousso. Analysis and interpretation of data: Moody, Dozier, Garza, Bowman, and Rousso. Drafting of the manuscript: Moody, Dozier, and Rousso. Critical revision of the manuscript for important intellectual content: Moody, Dozier, Garza, Bowman, and Rousso. Statistical analysis: Moody, Dozier, and Rousso. Administrative, technical, and material support: Moody, Dozier, Garza, and Rousso. Study supervision: Moody and Rousso.
Financial Disclosure: None reported.
Additional Contributions: Pam Brunson, BA (Rousso Facial Plastic Surgery), assisted in compiling the photographic data for this study and Fu-Shing Lee, PhD (Medical University of South Carolina), assisted in the statistical analysis.