A Historical Perspective on Two Approaches to the SMAS in Facial Rejuvenation Surgery

Abstract

The story of facelift surgery is usually told as a single line of increasingly deep dissection, arriving, in its most recent chapter, at dissection carried below the superficial musculoaponeurotic system (SMAS). This historical perspective revisits that story and finds something less tidy: two surgical traditions, distinguished not by chronology but by whether dissection is carried above or below the SMAS, that took shape within a few years of one another in the early-to-mid 1970s and developed largely side by side rather than one after the other. The first traces from Bettman's 1920 photographic documentation of facelift results through Aufricht's suture plication and Baker and Gordon's excisional technique to Mitz and Peyronie's 1976 anatomical description of the SMAS, which underlies the plication, SMASectomy, high-SMAS, and extended-SMAS techniques that approach the SMAS from above and remain in wide use today. The second traces from Tord Skoog's 1973 presentation of a musculocutaneous flap at the Baker-Gordon Symposium in Miami to Sam T. Hamra's development of the composite flap below the SMAS in the late 1980s, an approach that has recently been popularized under newer names. Read side by side, these histories complicate the common assumption that dissection below the SMAS is a later, more advanced refinement of dissection above it; the surviving record instead suggests two answers, arrived at in the same decade, to the same problem of an aging face—and, by Hamra's own account, the two traditions were not wholly unaware of one another: Paul Tessier, who supervised Mitz and Peyronie's anatomical work, is reported to have coined the term SMAS after he had become familiar with Skoog's technique. We argue that this history matters beyond the record itself, and, in our view, training programs, surgical marketing, and patient counseling can benefit from presenting both traditions as historically coequal approaches to the same anatomic structure, distinguished by plane of dissection rather than by presumed sophistication.