Perfusion of the Superficial Musculoaponeurotic System and the Superficial Temporal Fascia During Facelift, as Assessed by Indocyanine Green Angiography.

BACKGROUND

A clear understanding of the superficial musculoaponeurotic system (SMAS) perfusion during extended SMAS rhytidectomy is helpful for surgical planning and for elucidating the structural characteristics of the SMAS.

OBJECTIVES

The aim of this study was to determine the vascularity of the SMAS during extended SMAS rhytidectomy, as assessed using indocyanine green angiography (ICGA), and to discuss the clinical relevance of the SMAS perfusion pattern for surgical practice.

METHODS

A total of 20 patients who underwent extended SMAS rhytidectomy were evaluated intraoperatively. The perfusion patterns of the buccal-mandibular area SMAS and the superficial temporal fascia before and immediately after dissection were assessed by means of ICGA.

RESULTS

Perfusion of the buccal-mandibular area SMAS originated from a transverse facial artery perforator in the deep layer before dissection but was absent after dissection. No perfusion was observed after elevation of the buccal-mandibular area SMAS. In contrast, a prominent axial vessel was visible within the superficial temporal fascia. When this fascia was dissected, it was predominantly perfused by the parietal branch of the superficial temporal artery, which was present bilaterally in all patients. The superficial temporal fascia showed a marked peak in blood perfusion after dissection.

CONCLUSIONS

Perfusion of the buccal-mandibular area SMAS originated from a transverse facial artery perforator in the deep layer and remained poor during extended SMAS rhytidectomy. Because of the poor perfusion of the buccal-mandibular area SMAS after elevation, high-risk patients may benefit from composite facelifts, less extensive skin dissection, or preservation of the transverse facial artery perforator. The superficial temporal fascia can be harvested as an inferior-pedicled flap down to the zygomatic arch, whereas the buccal-mandibular area SMAS cannot be reliably harvested in this manner.

LEVEL OF EVIDENCE: 4 (THERAPEUTIC): For image description, please refer to the figure legend and surrounding text.