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 IJCS / Year: 2001 / Volume 1 - Number 2 / Original Papers
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Nikolay P. Serdev, MD, PhD
Pages: 20 - 27


Nikolay P. Serdev, M.D., Ph.D.

Head of Aesthetic Surgery and Aesthetic Medicine Medical Center - 11 “20th April” St., 1606 Sofia, BULGARIA

President of the Bulgarian Society of Aesthetic Surgery and Aesthetic Medicine


Since Mitz and Peyronie described in 1976 the superficial musculo-aponeurotic system, or SMAS, the SMAS facelift has become common and has risen into an operation to which others are compared. The author’s idea to lift the whole SMAS in the temporal direction is realised through the surgical technique “Temporal SMAS Lift by Minimal Hidden Incisions”. This ambulatory SMAS lift is helpful for changing the “mask of tragedy” into the “mask of comedy” in cases of beautification, soft tissue laxity early facial ptosis, and revision facelifts. OBJECTIVE: To develop a safe and effective ambulatory method to lift the facial mask, either as a single procedure or combined with other beautification and rejuvenation methods. METHODS: After the induction of local anesthesia 1 to 1.5 cm temporal incisions are made on both sides in the coronal line at the upper level of the temporal muscle, below the superior temporal crest line. A blunt dissection is passed in the temporal area between the coronal and the hairline in the space between the galea and the temporal fascial. The galea, presenting the SMAS is pulled up and fixed higher to the upper temporal line and temporal fascia with one or two sutures. Following this, the skin is closed with single sutures, without excision. Further, no dressing is necessary. The hair is washed on the next day and the sutures are removed in 7 days. RESULTS: This temporal SMAS lift changes the expression into happy, youthful and smiling appearance, gives apleasing beautification and rejuvenation of the skin, eyes, brows, and cheekbones and affects the lower face as well. It is also possible to combine this procedure with others, such as: rhinoplasty, chin and lip augmentation, fat reduction and augmentation, skin resurfacing or blepharoplasty. CONCLUSION: The “Temporal SMAS Lift by Minimal Hidden Incisions” provides a safe and effective ambulatory method for beautification especially in young patients, as well as for rejuvenation of early laxity and face ptosis.The very short recovery process permits patients to keep their normal life, work and social contacts.The temporal SMAS lift is part of the beautification surgery methods on the face.


Thirteen years ago, the author began correcting the superficial musculo-aponeurotic system (SMAS) in rhytidectomy. His interest in this procedure arose as a result from the conclusions made by Tessier in 1974, describing the SMAS. These conclusions were widely exhibited by two members of his team: Mitz and Peyronie in 1976 [1]. Since then many authors have dedicated their efforts to studying thesuperficial musculo-aponeurotic system, which gave rise to a lot of methods and publications. Since we began the SMAS lift treatment, we have dissected and mobilised it in different ways. The dissection, large at the beginning, became more limited, until the idea that we consider appropriate for achieving satisfactory results was reached. In 1994 the author firstly reported his concept of a temporal SMAS lift only, as a treatment of the suprazygomatic SMAS with effect on the infrazygomatic SMAS, i.e. the whole SMAS [2]. In the author’s hands this particular method became a routine ambulatory procedure for beautification, presented and demonstrated around the world [3-11 etc.].


In art and theatre, the faces called the “mask of tragedy” and the “mask of comedy” are well known and used to express age and status. The concept of the author’s surgical method named “Temporal SMAS Lift by Hidden Minimal Incisions” is to turn the “mask of tragedy” into a “mask of comedy”, i.e. to lift up “the subcutaneous facial mask” – the SMAS. Since soft tissue and skin are attached to the SMAS in the temporal region, the lifting of the SMAS in temporal direction reflects in lifting of the face and its most important elements in the same direction, (Fig. 1) and affects the lower face as well.

Fig.1. Mechanism of pulling the SMAS facial mask temporally from one point. Effect on the facial structures.

The same idea of a temporal lift is easy to create in the mind of any lady, beautiful enough or not (Fig.2).

Fig.2. Ladies with no exception are asking for a temporal lift of the face.

With age, the cranium looses on volume and ptosis is shown on the SMAS, which we can name Loose SMAS, and skin laxity gives to the face a sad and tired expression. On the other hand, structuring and positioning different face elements could be used not only in face ptosis of elderly individuals. Aesthetically wrong face angles could enhance a sad look also in young patients. Fixing the SMAS in a higher position aims repositioning of other soft tissue facial structures as well. Changing the position of the SMAS could restore the aesthetic angles, shape and proportions as a basis for beautification and rejuvenation, to give a happy, youthful appearance and a smiling expression not only to the elderly. With young patients the aim of the “temporal SMAS lift” should be beautification, based on face aesthetics (Fig. 3).

Fig. 3a, b. Before and after surgery. Temporal SMAS lift changes hanging angles of the eyebrow tail, lateral cantus of the eye and oral commissure a, b. Better expression of chick-bone prominence, due to the lifting of the skin and the fat pad. Additional rhinoplasty is made to correct the “golden dividing” of the facial proportions in 3 equal parts; Lip augmentation to equalize lip and eye-with eyebrow volume; Chin augmentation to obtain the “beauty triangle” and the straight line of the profile. Embellishment of the face is obtained and “smiling” expression is present (“mask of comedy” = fresh and young look).


The SMAS is spread from the platysma to the frontalis, and from the galea to the vertex, representing the same anatomic layer [12]. It lies deep to the subdermal vessels and superficial to the facial nerves. The SMAS acts as a suspension for the overlying facial skin and distributes forces of facial expression [13,14].

The galea, as the upper part of the SMAS, is a musculo-aponeurotic tissue and extends from the brow to the occipit and from the vertex to the zygomatic arch [15].

The temporal region or “temporal pocket” is located over the temporalis muscle, bordered by the superior temporal crest line above, by the lateral orbital rim in front, and by the zygomatic arch below [16-18]. The layer, covering the temporalis muscle, is a bright and thick aponeurosis, the Temporalis Fascia, also described as the “superficial layer”, “superficial temporal fascia”, intermediate temporal fascia, etc.[12][19-26]. At the level of the superior orbital rim, the temporalis fascia splits in two: Superficial and Deep layer of the temporalis fascia. These fascial layers enclose the intermediate fat pad.

An important landmark in the temporal region is the superficial temporal artery that can be easily palpated. The vein follows the same pattern [27]. The Frontal branch of the facial nerve, which innervates the frontalis muscle, the orbicularis oculi and corrugator supercili, is always medial and inferior to the anterior branch of the superficial temporal artery [28]. It lies in the deep layer of the fatty tissue interposed between the suprazygomatic extension of the superficial musculoaponeurotic system (SMAS) and the superficial leaflet of the temporal aponeurosis. It is considered to travel along a line connecting the base of the tragus to a point 1.5cm above the eyebrow.[29]


After the induction of local anesthesia, 1 to 1.5 cm temporal incisions are made on both sides, in the bicoronal line, at the level of the upper third of the temporal muscle, just below the superior temporal crest line. The incision opens the skin, the subdermal fat layer, and the galea (Fig. 4).

Fig 4a, b, c.

A. Superior temporal crest line and coronal line are marked blue. The temporal skin incision is limited 1 to 1.5 cm in the coronal line, marked with red line. The sutures of the temporal SMAS, to lift it to the point of fixation to the temporal fascia, are marked with black lines: first, in the direction of the eyebrow and the eye; second, in the direction of the lower face. Each one could be sufficient to solve different problems on the face.

b,c. The 1 to 1.5 cm long temporal skin incision is made in the coronal line.

A blunt dissection is passed temporally from the coronal to the hairline in the space between the galea and the temporal fascia, using a scalpel hand-piece (Fig. 5).

Fig. 5a, b, c. A. Blunt opening of skin and galea incision (tf = temporal fascia, g = galea). b. Blunt dissection between galea and temporal fascia. c. galea (g) and temporal fascia (tf) are visible

The galea is sutured using three simple steps: 1) A non-absorbable suture 3.0, with a large diameter needle, is introduced in the subgaleal space in the direction of the eyebrow and a puncture is done through the galea and the skin (Fig. 6a). 2) The needle is introduced back into the same puncture, then is passed subcutaneously and another puncture is done trough the skin in the lower face direction (Fig. 6b). 3) Through the last puncture back, the needle is introduced under the galea in the direction of the incision (Fig. 6c). All three steps need to be completed to fix the galea. 4) The next stitch is made through the upper temporal line and temporal fascia in the upper direction (Fig 6d). The suture of the galea to the temporal periosteum and fascia is done under elastic pressure (Fig 7a) Thus, the whole SMAS is pulled up in temporo-occipital direction. The galea, presenting the SMAS is pulled up and fixed higher to the temporal fascia with one or two sutures on each side (Fig 4a). Following this, the skin is closed with single sutures and no dressing is necessary (Fig. 7b). The next day hair washing is recommended to remove blood residuum. Sutures are removed in 7 days.

Fig. 6 a,b,c,d. A First stitch starting from the incision under the galea, b. second stitch above the galea, c. 3rd stitch under the galea back to the incision, d. 4th stitch trough the temporal fascia.

Fig. 7 a,b. A This particular suture is fixing galea in higher position to the temporal fascia, b. skin is closed.


716 patients were operated from January 1993 to May 2001. Patients’ age ranges from 19 to 53 years. The operation is done ambulatory and after washing and styling the hair, patients can return to their normal social life on the same day (Fig. 8a,b). The temporal SMAS lift has effects on the suprazygomatic area: it reduces the lateral and forehead wrinkles; raises the eyebrow tails and the lateral cantus of the eyes; reduces the crow's-foot wrinkles, raises the cheeks' fat pad into a better cheekbone prominence and tightens the skin. (Fig. 9a,b). The effects on the lower face are collateral. The SMAS elevates the oral commissure; it improves the skin adaptation reducing its cheek flaccidity; gives a clearer outline of the jaw (Fig. 10a,b). Generally, the method gives excellent results in younger and middle aged patients whose lower face is minimum to medium affected The tissues are repositioned to the desired higher youthful position. The temporal hair is preserved. There are no visible scars, no sign of operative intervention, and no "operated-on" appearance. A moderate tension in the face could be present for hours or days. The feeling is mostly pleasing. Only 7 patients described the tension as inconvenient for one or two days. During the first night 5 patients reported headache. On day 1 after surgery there is no swelling and business people can work normally. A lower eyebrow swelling could appear on day 2 and 3 in approximately 30 % of the patients and can be prevented by resting in the supine position during the first two days. Two patients had lower lid bruising on one side and another one – on both sides. Three patients reported a crust formation and a liquid formation under the crust. The reason was interposition of hair in the suture sling for galea fixation. After its removal, the wounds healed in approximately two days. A patient had the same problem in another country and the surgeon removed a suture. No other infections, no hematomas or damage on the facial nerve were observed. A palpable fold in the temporal area could be present in some cases and it stays for a week.
The most important thing in face lifting is its long-term fixation. Numerous factors act against face stability, such as gravity and mimic. The longevity of the result is improved due to the SMAS fixation. This is best seen years after surgery in cases of a unilateral temporal SMAS lift in facial paralysis, post traumatic and postoperative canthal abnormalities. (Fig. 11 a,b).
Two patients, who could not see the difference, despite the photograph demonstrations, contested the aesthetic result. The effect of lifting angles was not satisfactory with 5 patients. With 3 of them the operation was repeated after 3 to 5 years.

Fig. 8 a,b. Before and immediately after a temporal SMAS lift and rhinoplasty. The absence of visible signs of operation permits immediate return to social life.

Fig. 9 a,b. Before and after a temporal SMAS lift. Visible elevation of the eyebrow tail and the lateral cantus of the eye reduction of the crow's-foot wrinkles elevation of the cheeks' fat pad into a better cheekbone prominence; tightening and beautification of the skin.

 Fig, 10 a,b. Before and after a temporal SMAS lift. Visible changes in the suprazygomatic as well as in the infrazygomatic area. Beautification and rejuvenation are obtained.

   Fig. 11a,b. Before and after a unilateral temporal SMAS lift in facial paralysis. A 4-year result. The whole left side is elevated and the nose is positioned in the middle by the temporal SMAS pull.


Currently there are plenty of techniques used for face-lifts: conventional rhytidectomy composite face-lifting, deep layer rhytidectomy sub-SMAS, extended face-lifting, subcutaneous temporofacial lift combined with SMAS suspension, medial SMAS lift with aggressive temporal skin takeout, temporal lift via blepharoplasty approach, but stretching the skin solely is obsolete. New techniques were proposed, such as endoscopic subcutaneous and SMAS, subperiosteal, extended face and browlift etc. [30-48].There is no general agreement and no definitive answer as to which operative technique is most effective or preferable in each specific case. This is due to the subjective nature of aesthetics and desires, to the variability of skills and anatomy.

In the last years an increasing number of patients ask for mal result with minimal surgery and recovery time, corresponding to the modern lifestyle. The temporal SMAS lift by minimal hidden incisions is the most preferred one by our patients as an optimal solution for face beautification that preserves the natural look.

Fig. 12 a, b. Before and after a temporal SMAS lift, rhinoplasty and ultrasonic liposculpture of the double chin. Anatomically different problems on the face are solved in one session using different surgical techniques.


The temporal SMAS lift is a nice weekend ambulatory procedure that gives a pleasing rejuvenation and beautification of the skin, eyes, brows, cheekbones, and most importantly, changes the expression. In young ladies, only one suture per side is usually enough to lift the lateral cantus of the eye, the eyebrow and to pull the ptotic malar fat back in place to form a nice malar eminence.  It is also possible to combine this procedure with other procedures such as: rhinoplasty, chin and lip augmentation, fat reduction and augmentation, skin resurfacing or blepharoplasty (Fig. 12a, b).
The SMAS lift provides a safe and effective method for beautification, as well as for rejuvenation in early laxity and face ptosis, and for some revision facelifts.


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Contact address:

Nikolay P. Serdev, MD, PhD
Aesthetic Surgery and Aesthetic Medicine Medical Center
11 Dvadeseti April Str., 1606 Sofia, Bulgaria
Tel: +359 88 802004
Fax : +359 2 9515668
E-mail :


Bulgarian Society of Aesthetic Surgery and Aesthetic Medicine

Send for publication: 31 05 2001

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 IJCS / Year: 2001 / Volume 1 - Number 2 / Original Papers
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