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SMAS Four letters on guard of a young oval

“Doctor, do you do SMAS lifting?” – often ask patients cosmetologists.

“No, this is a surgical area of ​​responsibility,” cosmetologists answered ten years ago. But the development of high technology and the immersion in the world of anatomy at dissection courses have expanded the capabilities of cosmetologists – and now knowledge of the superficial muscular aponeurotic system (PMAS), or superficial musculoaponeurotic system (SMAS) has tightly entered the everyday practical life of cosmetologists.

SMAS (from the English superficial musculoaponeurotic system). These four letters are called the superficial muscle-aponeurotic layer.

For a long time, SMAS was known only to plastic surgeons who worked with surgical correction methods, but in 2009 the Ulthera® System was introduced in Russia, which, thanks to micro-focused ultrasound, made it possible to affect the ligaments that are part of SMAS.

Historical excursion
Dr. Joel Pessa, author of the Facial Topography: Clinical Anatomy of the Face textbook, in one of his articles on SMAS anatomy, notes: “The topic of fascia – and especially their division and distribution for the formation of fascial layers and voids – has been a source of heated debate throughout the history of medicine. Confusion over the basic terms describing the fascia led the great anatomist Malgaign to the idea formulated by him almost 200 years ago that “the cervical fascia appears every time in a new form under the pen of each author who undertakes to describe them” ”[Pessa 2016].

This confusion has even led to proposals to ban the use of the term “spaces” [see Guidera et al, 2014] and replace it with other, more anatomically accurate.

In 2002, in the Austrian city of Innsbruck, a curious publication of a group of anatomists came out, which, after conducting histological studies of the facial and cervical preparations of a person, stated the following: “In the face, there is no presence of SMAS anywhere except in the salivary gland. In this area, SMAS is thick and attaches to the parotid sheath. However, in the buccal region it becomes thinner, disappears and does not lend itself to dissection. ” Further, the authors write that they also did not visualize SMAS in the neck, instead they note that they were the first to identify the fascia covering both sides of platism. And it is these fascias that are topographically associated with the subcutaneous layers of the adjacent areas. And it is these fascias that should be interpreted as “neck markers” during surgical operations, and not be guided by the so-called SMAS [Gardetto et al. 2003].

For the first time, SMAS was discovered and described as a muscle-aponeurotic structure at the beginning of the 20th century by Henry Gray in his classic and canonical textbook on human anatomy “Gray Anatomy”. He noted that fasciae are fibroareolar, or aponeurotic plates, of varying thickness and strength, and are found in different areas of the body, including internal organs (such as the stomach).

In addition, superficial fascia are found subcutaneously in almost the entire body. These fascias bind the skin to the deep, or aponeurotic, fascia and consist of fibroareolar tissue containing different amounts of fat in its structure. Superficial fascia also accompany muscles, such as platy and palpebrarum orbicularis in the eyelids. In addition, the fascia connects the skin with the underlying tissues, facilitates skin movement, serves as a “channel” for blood vessels and nerves that nourish the skin, and retain body heat, since the fat contained in the areoles does not conduct heat well.

An important year in the history of this anatomical zone was the distant 1974th. It was then that two plastic surgeons, Vladimir Mitz and Martin Peyroni, first introduced the scientific abbreviation SMAS, which was assigned to it.

Then these authors cited their description and topography, which are now included and cited in the overwhelming number of scientific articles and textbooks: “There is a superficial muscular aponeurotic system (SMAS) in the parotid and buccal region … This area should be considered with special attention when planning and conducting surgical interventions on the face … ”[Mitz, Peyronie 1976: 80].

Anatomical excursion
How did SMAS describe Mitz and Peyronie?

Using various research methods (including dissection, arteriography, macroscopic and microscopic examinations, ultraradiography and histology), scientists have found that SMAS is always present in the buccal and parotid salivary glands. “Sometimes it is a thick layer, sometimes thin, but it is closely intertwined with the other fascia superficialis of the face and neck … SMAS divides subcutaneous fat into two layers. Superficially to it, small fat lobules are enclosed in fibrous septa (septa), distributed from the SMAS towards the dermis. The deeper we enter the tissue, the fatty lobules become richer and more abundant, it lies between the deep facial muscles and is no longer divided by such fibrous septa. ”

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