The purpose of this study was to investigate the morphology of the superficial musculoaponeurotic system (SMAS). Eight embalmed cadavers were analyzed: one side of the face was macroscopically dissected; on the other side, full-thickness samples of the parotid, zygomatic, nasolabial fold and buccal regions were taken. In all specimens, a laminar connective tissue layer (SMAS) bounding two different fibroadipose connective layers was identified. The superficial fibroadipose layer presented vertically oriented fibrous septa, connecting the dermis with the superficial aspect of the SMAS. In the deep fibroadipose connective layer, the fibrous septa were obliquely oriented, connecting the deep aspect of the SMAS to the parotid-masseteric fascia. This basic arrangement shows progressive thinning of the SMAS from the preauricular district to the nasolabial fold (p < 0.05). In the parotid region, the mean thicknesses of the superficial and deep fibroadipose connective tissues were 1.63 and 0.8 mm, respectively, whereas in the region of the nasolabial fold the superficial layer is not recognizable and the mean thickness of the deep fibroadipose connective layer was 2.9 mm. The connective subcutaneous tissue of the face forms a three-dimensional network connecting the SMAS to the dermis and deep muscles. These connective laminae connect adipose lobules of various sizes within the superficial and deep fibroadipose tissues, creating a three-dimensional network which modulates transmission of muscle contractions to the skin. Changes in the quantitative and qualitative characteristics of the fibroadipose connective system, reducing its viscoelastic properties, may contribute to ptosis of facial soft tissues during aging.

1.
Barton, F.E., Jr (1992) The SMAS and the nasolabial fold. Plast Reconstr Surg 89: 1054–1057.
2.
Bichat, X. (1803) Traité d’anatomie descriptive, ed 2. Paris, Brasson, p 64.
3.
De Caro, R., F. Aragona, A. Herms, D. Guidolin, E. Brizzi, F. Pagano (1998) Morphometric analysis of the fibroadipose tissue of the female pelvis. J Urol 160: 707–713.
4.
Ferreira, L.M., B. Hochman, R.F. Locali, L.M. Rosa-Oliveira (2006) A stratigraphic approach to the superficial musculoaponeurotic system and its anatomic correlation with the superficial fascia. Aesthetic Plast Surg 30: 549–552.
5.
Furnas, D.W. (1989) The retaining ligaments of the cheek. Plast Reconstr Surg 83: 11–16.
6.
Gardetto, A., J. Daberning, C. Rainer, J. Piegger, H. Piza-Katzer, H. Fritsch (2003) Does a superficial musculoaponeurotic system exist in the face and neck? An anatomical study by the tissue plastination technique. Plast Reconstr Surg 111: 664–672.
7.
Gassner, H.G., A. Rafii, A. Young, C. Murakami, K.S. Moe, W.E. Larrabee (2008) Surgical anatomy of the face. Arch Facial Plast Surg 10: 9–19.
8.
Ghassemi, A., A. Prescher, D. Riediger, A. Axer (2003) Anatomy of the SMAS revisited. Aesthetic Plast Surg 27: 258–264.
9.
Gosain, A.K., N.J. Yousif, G. Madiedo, D.L. Larson, H.S. Matloub, J.R. Sanger (1993) Surgical anatomy of the SMAS: a reinvestigation. Plast Reconstr Surg 92: 1254–1263.
10.
Har-Shai, Y., S.R. Bodner, D. Egozy-Golan, E.S. Lindenbaum, O. Ben-Izhak, V. Mitz, B. Hirshowitz (1997) Viscoelastic properties of the superficial musculoaponeurotic system (SMAS): a microscopic and mechanical study. Aesthetic Plast Surg 21: 219–224.
11.
Huggins, R.J., M.E. Freeman, J.B. Kerr, B.C. Mendelson (2007) Histologic and ultrastructural evaluation of sutures used for surgical fixation of the SMAS. Aesthetic Plast Surg 31: 719–724.
12.
Isse, N.G. (1997) Endoscopic facial rejuvenation. Clin Plast Surg 24: 213–231.
13.
Jost, G., Y. Levet (1984) Parotid fascia and face lifting: a critical evaluation of the SMAS concept. Plast Reconstr Surg 74: 42–51.
14.
Koornneef, L. (1979) Orbital septa: anatomy and function. Ophthalmology 86: 876–880.
15.
Lockwood, T.E. (1991) Superficial fascial system (SFS) of the trunk and extremities: a new concept. Plast Reconstr Surg 87: 1009–1018.
16.
Macchi, V., C. Tiengo, A. Porzionato, A. Parenti, C. Stecco, F. Bassetto, R. Scapinelli, G. Taglialavoro, R. De Caro (2007) Musculocutaneous nerve: histotopographic study and clinical implications. Clin Anat 20: 400–406.
17.
McKinney, P., J. Gottlieb (1985) The relationship of the great auricular nerve to the superficial musculoaponeurotic system. Ann Plast Surg 14: 310–314.
18.
Mendelson, B.C. (2001) Surgery of the superficial musculoaponeurotic system: principles of release, vectors, and fixation. Plast Reconstr Surg 107: 1545–1552.
19.
Mendelson, B.C., A.R. Muzaffar, W.P. Adams, Jr (2002) Surgical anatomy of the midcheek and malar mounds. Plast Reconstr Surg 110: 885–896.
20.
Mitz, V., M. Peyronie (1976) The superficial musculoaponeurotic system (SMAS) in the parotid and cheek area. Plast Reconstr Surg 58: 80–88.
21.
Owsley, J.Q., Jr (1983) SMAS-platysma facelift. A bidirectional cervico-facial rhytidectomy. Clin Plast Surg 10: 429–440.
22.
Pensler, J.M., J.W. Ward, S.W. Parry (1985) The superficial musculoaponeurotic system in the upper lip: an anatomical study in cadavers. Plast Reconstr Surg 75: 488–494.
23.
Ramirez, O.M. (1998) High-tech facelift. Aesthetic Plast Surg 22: 318–328.
24.
Ramirez, O.M. (2001) Full face rejuvenation in three dimensions: a ‘face-lifting’ for the new millennium. Aesthetic Plast Surg 25: 152–164.
25.
Ramsaroop, L., B. Singh, L. Allopi, J. Moodley, P. Partab, K.S. Satyapal (2006) The surgical anatomy of the parotid fascia. Surg Radiol Anat 28: 33–37.
26.
Rees, T.D., S.J. Aston (1977) A clinical evaluation of the results of submuscular-aponeurotic dissection and fixation in face lifts. Plast Reconstr Surg 60: 851–859.
27.
Scapinelli, R., C. Stecco, A. Pozzuoli, A. Porzionato, V. Macchi, R. De Caro (2006) The lumbar interspinous ligaments in humans: anatomical study and review of the literature. Cells Tissues Organs 183: 1–11.
28.
Standring, S., H. Ellis, J. Healy, D. Johnson, A. Williams (2005) Gray’s Anatomy, ed 39. London, Churchill Livingstone, pp 456–458.
29.
Stuzin, J.M., T.J. Backer, H.L. Gordon (1992) The relationship of the superficial and deep facial fascias: relevance to rhytidectomy and aging. Plast Reconstr Surg 89: 441–449.
30.
Thaller, S.R., S. Kim, H. Patterson, M. Wildman, A. Daniller (1990) The submuscular aponeurotic system (SMAS): a histologic and comparative anatomy evaluation. Plast Reconstr Surg 86: 690–696.
31.
Thiel, W. (1992) Die Konservierung ganzer Leichen in natürlichen Farben. Ann Anat 174: 185–195.
32.
Wilhelmi, B.J., A. Mowlavi, M.V. Neumeister (2003) The safe face lift with bony anatomic landmarks to elevate the SMAS. Plast Reconstr Surg 111: 1723–1726.
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