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DOI: 10.1177/1090820X14528947
2014 34: 661 originally published online 17 April 2014 Aesthetic Surgery Journal
Xiaoqing Hu, Zhijun Wang, Qi Wang, Chen Zhang, Gang Hu and Hongzhi Qin
System? A Preliminary Biomechanical Study
Are There Differences Between the Upper and Lower Parts of the Superficial Musculoaponeurotic

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Aesthetic Surgery Journal
2014, Vol. 34(5) 661 667
2014 The American Society for
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DOI: 10.1177/1090820X14528947
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Facial Surgery
Although absorbable filler injections and suture suspen-
sion are increasingly popular approaches for facial rejuve-
nation, traditional rhytidectomy has unique advantages.
This procedure is often the only choice for elderly patients
who display obvious signs of skin relaxation and for
patients who seek a very significant change in their appear-
ance. Tightening the preauricular or the lateral area of the
superficial musculoaponeurotic system (SMAS) in differ-
ent directions is the key component of rhytidectomy proce-
dures. Plastic surgeons tend to view the SMAS as 1
mechanical unit, and whether there are any biomechanical
differences between the upper and the lower parts of the
528947AESXXX10.1177/1090820X14528947Aesthetic Surgery JournalHu et al
research-article2014
Dr X. Hu is a Clinical Attending Surgeon and Drs Z. Wang and
Zhang are Professors of Plastic Surgery in the Department of Plastic
Surgery, Affiliated Xinhua Hospital of Dalian Medical University,
LiaoNing, China. Dr Q. Wang is a Clinical Attending Physician in
the Department of Pediatric Intensive Care, Childrens Hospital of
Zhengzhou, HeNan, China. Drs G. Hu and Qin are Professors of
Plastic Surgery in the Department of Plastic Surgery, First Affiliated
Hospital of Dalian Medical University, LiaoNing, China.
Corresponding Author:
Dr Zhijun Wang, Department of Plastic Surgery, Affiliated Xinhua
Hospital of Dalian Medical University, No. 148 Wansui Rd,
Shahekou District, Dalian, 116021, LiaoNing, China.
E-mail: plasticvip@163.com
Are There Differences Between the
Upper and Lower Parts of the Superficial
Musculoaponeurotic System? A Preliminary
Biomechanical Study
Xiaoqing Hu, MMS; Zhijun Wang, MD; Qi Wang, MB;
Chen Zhang, MD; Gang Hu, MD; and Hongzhi Qin, MMS
Abstract
Background: The superficial musculoaponeurotic system (SMAS) becomes thinner and gradually disappears from the midface. In rhytidectomy,
manipulation of the SMAS occurs in the lateral area, and previous research has focused primarily on the SMAS region as a whole.
Objectives: In this preliminary study, the authors compared the viscoelasticity of the upper and lower regions of the SMAS using biomechanical
techniques.
Methods: Two adjacent projection regions of the SMAS were designated: region 1 and region 2, representing the upper and lower parts, respectively.
The SMAS tissues from 8 fresh-frozen cadaver heads were cut into 64 samples before biomechanical testing, and the following variables were recorded
for subsequent analysis: stress-strain curve, elastic modulus, ultimate strength, and elongation at break.
Results: The stiffness of region 1 was markedly greater than that of region 2. Energy dissipation was greater in region 2. Elastic modulus and ultimate
strength were significantly higher for region 1, and elongation at break was longer in region 2. The fit curve of the 2 regions deviated markedly.
Conclusions: The biomechanical properties of the upper and lower regions of the lateral SMAS are functionally different. Such knowledge will help
refine the planning and design of facial surgery and improve outcomes for patients who undergo rhytidectomy.
Keywords
superficial musculoaponeurotic system (SMAS), biomechanics, rhytidectomy, rejuvenation, facelift, viscoelasticity
Accepted for publication October 21, 2013.
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662 Aesthetic Surgery Journal 34(5)
SMAS has not been reported previously. Our research pro-
vides a preliminary examination and analysis.
METHODS
Preliminary work was performed on multiple specimens to
determine the optimal assessment technique. For the
study, 8 fresh-frozen human cadaveric heads, which had
been stored at 60C, were selected. The age range of the
cadavers was 45 to 65 years (average age, 58.3 2.6
years); 5 were male, and 3 were female. As deep scarring
could have affected the evaluation, specimens without
facial scars or surgical operations, including facelifts, were
selected. Dissections were performed after the cadaveric
heads had thawed for 48 hours at 4C.
Macroscopic Dissection
Because the SMAS thins and gradually disappears in the
midface, we focused on the SMAS in the lateral face to
determine clinical applications for aesthetic surgery. In
accordance with previous reports
1,2
and the practical
aspects of SMAS facelift technology, we defined 2 adjacent
projection regions of facial skin: region 1 and region 2
(Figure 1).
Region 1
Region 1 includes the upper part of the SMAS, just below
the zygomatic arch, extending anterior of the tragus to the
lateral edge of the zygomatic major muscle, then posteri-
orly to the upper edge of the platysma beneath the lobulus
auriculae. This triangular projection was denoted as the
aponeurotic part of the pretragal SMAS, superficial to the
parotid fascia.
Region 2
Region 2, a polygonal projection beneath region 1, repre-
sents the lower part of the SMAS, superficial to the mas-
seter fascia. It extends downward inferolaterally along the
anterior edge of the masseter muscle, intersecting with the
rim of the mandible.
Dissection Process
Once the cadaver heads thawed, the skin over the 2 regions
was dissected sharply, undermined, and lifted. This pro-
cess allowed for full visualization of the SMAS tissue over-
lying the parotid fascia and masseter fascia. The SMAS
was separated superficial to the parotid fascia through the
loose connection between the 2 soft-tissue layers, thus
avoiding damage to the parotid fascia and parotid gland.
The SMAS was harvested in the lateral face approximately
0.5 cm from the zygomatic and masseteric ligaments.
During dissection, we noted that the SMAS of region 2 con-
tained substantial muscle fibers resembling compact strips
running transversely and parallel to the platysma muscle
in the cervical region.
Preparation of Samples
The SMAS tissues of region 1 and region 2 were harvested
separately and then cut into multiple samples. Each
cadaver provided a total of 8 samples: 4 from each region
of the SMAS. The preparation of each cadaver sample set,
including SMAS dissection, was conducted at a tempera-
ture of 4C and completed within 1 hour. Because of the
limited number of cadavers, the direction of the sample
either parallel or perpendicular to the headwas not con-
sidered a condition for grouping. The samples were
trimmed to a dumbbell shape to ensure that they could be
broken in the center. The size of each sample was designed
Figure 1. The 2 adjacent projection regions of the superficial
musculoaponeurotic system (SMAS) on facial skin. Region 1,
represented by the red triangle A-B-C, includes the upper part
of the SMAS, superficial to the parotid fascia and just below
the zygomatic arch. Region 1 extends from point A (anterior
of the tragus) to point B (lateral edge of the zygomatic major
muscle) and then posteriorly to point C at the upper edge of
the platysma beneath the lobulus auriculae. Region 2, which
lies beneath region 1 and is represented by the blue polygon
B-C-D-E, includes the lower part of the SMAS, superficial to
the masseter fascia. This area extends downward from point B,
inferolaterally along the anterior edge of the masseter muscle
to point E, intersecting with the mandibular rim. Point D is the
mandibular angle.
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Hu et al 663
to coincide with the serrated grips of the Instron universal test-
ing machine (model 5567A; Instron, Norwood, Massachusetts).
For uniformity, all samples were measured at their mid-
point. The length, width, and thickness of each sample
were approximately 10 mm, 10 mm, and 3 mm, respec-
tively. All dissections and SMAS sample preparations were
performed by the primary author (X.H.) to ensure that the
samples were as identical as possible.
Biomechanical Testing
Prior to each measurement, the Instron machine was cali-
brated and zeroed out. The sensing elementa key com-
ponent of measurement rangewas 100 N. Testing was
performed with uniaxial tension in parallel with each sam-
ples long axis. The control mode of test setup parameters
was x-y (ie, the display mode of coordinate axes), accord-
ing to various biomechanical test schematics. The x-axis
indicated tensile displacement (ie, change in length of
deformation) or the Green strain (ie, mechanical index of
deformation), with = (
2
1)/2 (the stretch ratio =
L/L
0
, where L and L
0
represented the stretched and initial
lengths, respectively). The y-axis indicated tensile loading
force or the Lagrange stress (force per unit area).
The SMAS samples of each cadaver were stored in a
moist, room-temperature environment (25C) throughout
the experiment. Testing of each cadaver was completed
within 1 hour. Testing for viscoelastic characteristics dem-
onstrated the hysteresis effect and stress-strain procedure.
3

In the typical phenomenon of hysteresis loop, the strain
lags behind stress and energy loss in the process of succes-
sive loading and unloading cycles. For stress-strain testing,
the samples were pulled at a displacement rate of 10 mm/
min until failure, at which time the Lagrange stress
required to rupture the tissues was measured. Ultimate
strength is defined as the maximum level of stress (mea-
sured in megapascals) that the tissue can sustain, calcu-
lated as force (measured in newtons) divided by the
original, unstrained cross-section area of the specimen
(measured in square meters). The following measurements
were automatically collected by the computer for subse-
quent analyses: stress-strain curve, the elastic modulus
(Youngs modulus E), ultimate strength, and the percent-
age of elongation at break. Youngs modulus E was defined
as the slope of the elastic region (near linear part) of the
stress-strain curve.
Statistical Analysis
The t test was used to identify differences in the biome-
chanical properties of the SMAS between region 1 and
region 2 (df = 31, paired samples t test, 2-tailed). Statistical
significance was defined as P < .05 (SPSS, version 13.0;
SPSS, Inc, an IBM Company, Chicago, Illinois).
RESULTS
Hysteresis Loop
Each sample was stretched at a rate of 10 mm/min to the
same displacement point. A series of hysteresis loops were
shown with loading and unloading cycles until a stable con-
dition was reached; therefore, the sample was precondi-
tioned. The loading curves lay outside the unloading curves,
and the stretch ratio of the loading curves was lower than
that of the unloading curves (Figure 2). Because a sample
was loaded in the elasticized region, it returned to its origi-
nal shape through the unloading process. While all loops
decreased gradually to an equilibrium level, the stiffness
between the 2 regions was markedly different. For clarity,
the 2 representative curves at the third circle of each test for
regions 1 and 2 were isolated in a load-vs-displacement pre-
conditioned curve (Figure 3). Measured stiffness and energy
dissipation are shown in Table 1. No statistically significant
difference was found within the same region. Average stiff-
ness was markedly greater in region 1 (0.21 0.02 vs 0.14
0.03 in region 2). The area enclosed by the curve was
0.57 0.09 for region 1 and 2.10 0.76 for region 2.
Stress-Strain Curve
The average curve (Figure 4) showed that the elastic mod-
ulus (Youngs modulus E) and ultimate strength of region
1 were significantly higher than those of region 2; however,
the percentage of elongation at break was shorter in region
1. The average values of all specimens from both regions
are summarized in Table 2. As with hysteresis testing, no
significant difference was found among samples within the
same region.
Figure 2. The hysteresis loop in successive cycles: the
loading curves lay outside the unloading curves. All loops
decreased gradually to a level of equilibrium. Region 1 (left)
exhibited greater stiffness than did region 2 (right). SMAS,
superficial musculoaponeurotic system.
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664 Aesthetic Surgery Journal 34(5)
We evaluated the stress-strain curve of the 2 regions
with a 5-order polynomial model, which provided a good
fit for the experimental data. The various parameters are
listed in Table 3. Results showed obvious deviation
between the curves of the 2 groups. The A
0
of region 1
(34.86 E-03) was approximately 10 times that of region 2
(3.08 E-03), but the subsequent parameters (A
1-5
) were
similar for the 2 regions.
DISCUSSION
Tightening the SMAS has become an essential part of rhyt-
idectomy procedures: in most facelift techniques, surgeons
tighten the SMAS to counteract the sagging force of the
facial soft tissue. Because the SMAS has customarily been
regarded as a whole, and previous reporting
4
has focused
on biomechanical properties of the SMAS as a whole, less
is known about the mechanical behavior of the different
parts of this system. Better understanding of the viscoelas-
tic properties of the SMAS can guide surgeons in selecting
optimal rhytidectomy techniques. Our study was con-
ducted to elucidate the biomechanical differences between
the upper and lower parts of the lateral SMAS (regions 1
and 2, respectively). The study compared stiffness, energy
dissipation of hysteresis loops, the elastic modulus
(Youngs modulus E), ultimate strength, and the elonga-
tion of the stress-strain curve at break. The SMAS tends to
thin out from the lateral face to the central face, and the
properties mentioned above may be changed gradually,
and thus our data are intended to provide general guidance
for the biomechanics of the lateral SMAS. Examination of
specific gradients is beyond the scope of this study.
The stiffness of SMAS region 1 was greater than that of
region 2, which coincided with comparative findings of the
elastic modulus revealed by stress-strain curves (Figure 4).
The constant variables helped illustrate the relationship
between a given load and the resulting displacement
within the elasticized range. It is suggested that region 1
may have maintained stronger elasticity, thus resisting
deformation in the direction of the applied load. This find-
ing may help to explain why the lower part of the lateral
face tends to sag before the upper part. The relationship
between stress and strain is actually an interatomic force
with atomic spacing. Elastic deformation is a reversible
change of atomic spacing under external force. The elastic
modulus has a close relationship with interatomic force
and atomic spacing, due mainly to the interatomic bonding
nature and bonding force.
For nonideal elastic material (ie, stress and strain do not
satisfy the linear relationship, as per Hookes law, or the
material is a nonlinear elastic body), stress and strain are
asynchronous. The unloading curve does not overlap the
loading curve; thus, the 2 curves form a closed loop known
as the hysteresis loop. The hysteresis loop phenomenon
indicates that the deformation work (energy dissipated in
the deformation process) consumed by material during
loading is larger than that released during unloading. The
energy absorbed in the deformation process is known as
internal dissipation, which causes damage accumulation.
The area encircled by the hysteresis loop, and representing
the dissipation, is applied as a damage variable of fatigue
accumulation. In this study, energy dissipation was greater
in region 2. We speculate that SMAS region 2 is more prone
to fatigue damage, and this information may serve as a
reference for obtaining better outcomes from primary and
secondary rhytidectomy.
5
Contrary to another study on facial retaining ligaments,
6

the stress-strain curves in our study lacked obvious yield
phenomenon. (Beyond the elastic limit, we observed obvi-
ous deformation of samples even without increasing
stress.) Compared with the ligament, the SMAS showed a
Table 1. Stiffness and Dissipation of Regions 1 and 2
Measurement Region 1 Region 2 t P
Stiffness, N/mm 0.21 0.02 0.14 0.03 4.922 .001
Dissipation, Nmm 10
2
0.57 0.09 2.10 0.76 4.491 .002
Figure 3. Two representative preconditioned curves at the
third cycle in region 1 (left) and region 2 (right). The area
representing the dissipation enclosed by the hysteresis loop
(shown in yellow) was smaller in region 1. SMAS, superficial
musculoaponeurotic system.
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Hu et al 665
more inhomogeneous and continuous yield. Ultimate
strength, which refers to the maximum stress the tissue
can sustain, reflects the resistance to maximum uniform
deformation. Our analysis showed that ultimate strength
was significantly higher in region 1, which may indicate
that overlying skin tension decreased as a result of SMAS
support. This may lead to improved long-term results in
region 1 relative to region 2. The range of ultimate strength
observed in our investigation (1.19 0.20 to 1.59 0.18
Mpa; 172.55 29.00 to 230.55 26.10 psi) is similar to
that obtained by Trussler et al
7
(224.97 57.9 psi) but
falls between the data of the young and the old groups
reported by Saulis et al.
8
(The average cadaver age was
58.3 2.6 years in our study vs 69 years [range, 53-84
years] in Saulis et al.)
The amount of elongation at break depends on the flex-
ibility of the molecular structure (ie, conformational
change ability). Among other factors, molecular weight
depends on the state of aggregation and multiphase struc-
ture, and high molecular weight produces greater flexibil-
ity and elongation. When cross-linking density increases,
the slippage within the molecular chain will be reduced,
tensile strength will increase, and elongation at break will
decrease. Tensile deformation represents an energy-
consuming process of conformational changes. Higher elon-
gation at break means that the tissues demonstrate greater
impact-resistant ability. In this study, SMAS region 2 pro-
vided higher elongationand therefore better ductility
and was more conducive to stress and safety reserves.
To take advantage of the high strength exhibited in
region 1, SMAS plication would likely be more beneficial
than SMAS-ectomy. Plication may counteract fatigue and
premature relaxation, provided that the lateral face resec-
tion overlaps region 2. Because the SMAS thins in midface,
its strength might be reduced gradually from the lateral to
the central face. We suggest that the excised or translo-
cated part of the lateral SMAS might be overlapped medi-
ally to enhance the effect of midface rhytidectomy. Because
adhesions or scars form between the SMAS and its adja-
cent layers during healing after rhytidectomy, both the
SMAS and composite tissues will endure stress. The bio-
mechanical performance of the SMAS also will be affected
by adjacent tissues, which involves a dynamic, interactive
process.
Through previous studies,
9-14
the role of the SMAS in facial
rejuvenation procedures has gradually become clearer. The
Figure 4. Stress-strain curves without obvious yield points. Samples were pulled at a displacement rate of 10 mm/min until
failure. The elastic modulus (or Youngs modulus E), ultimate strength, and percentage of elongation at break were compared.
Youngs modulus E and ultimate strength (right) were higher in region 1 (red) than in region 2 (blue); the elongation at break
(left) was shorter in region 1. The force level (black arrow) placed on the superficial musculoaponeurotic system (SMAS) in
our clinical setting was only a minor portion of the samples ultimate strength.
Table 2. Biomechanic Indices of Regions 1 and 2
Index Region 1 (n) Region 2 (n) t P
Youngs modulus E, Mpa 3.54 1.00 (32) 2.38 0.17 (32) 2.798 .019
Ultimate strength, Mpa 1.59 0.18 (32) 1.19 0.20 (32) 3.648 .004
Elongation at break, % 127.37 20.48 (32) 163.07 17.52 (32) 3.243 .009
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666 Aesthetic Surgery Journal 34(5)
SMAS is a continuous, organized fibrous network that con-
nects the facial muscles as central aponeurosis,
15
a complex
tissue comprising collagen fibers, elastic fibers, and fat cells.
16

As soft tissue, the SMAS possesses viscoelasticity and thus
exhibits nonlinear mechanical behavior as a stress-distribut-
ing and load-absorbing structure. The biomechanical differ-
ences between region 1 and region 2 may relate to the
proportion of muscular and aponeurotic components of the
upper and lower parts of the SMAS. Mechanical behavior of
the SMAS is primarily determined by the intrinsic properties
of its components, which in turn may influence collagen
fibers, elastic fibers, and fat cells, resulting in an adaptation of
synthesis or arrangement of these components. In our previ-
ous pathological studies, we observed a difference in the pro-
portion of fibrous components between the 2 regions.
However, this finding alone is insufficient for drawing final
conclusions; detailed biopsies of both regions of the SMAS
are needed.
There are several limitations to this study. Because find-
ings from cadaveric samples do not necessarily translate to
clinical practice, the biomechanical properties of the 2 SMAS
regions may be different for patients undergoing live surgery.
This study simulated the SMAS rhytidectomy without verify-
ing the parotid fascia. Whether or not the parotid fascia was
included, it would be unrealistic to investigate each patient
via biopsy during live surgery. Another limitation of our study
is the small number of specimens, which does not permit
data stratification by age or sex. Therefore, we do not yet
know whether age and sex affect strength or the other factors
evaluated in our study. This preliminary study warrants fur-
ther research and analysis to determine the optimal technique
for repositioning facial soft tissue, increasing longevity of the
effect, and strengthening the SMAS.
CONCLUSIONS
Rectifying facial relaxation is essential to achieving a youth-
ful appearance after rhytidectomy. Various techniques have
been used to accomplish this, including tightening the pre-
auricular or lateral part of the SMAS. Rather than simply
treating the lateral SMAS as a single unit, it is important to
understand the distinct biomechanical differences that exist
between the upper and lower regions of this complex sys-
tem, as described in this preliminary study. Our findings
may be helpful for estimating the distribution of stress and
strain in these 2 regions of the SMAS and for refining the
design of a suitable vector of elevation or facial shaping in
rhytidectomy surgery. Subsequent experiments have been
designed to further our knowledge of the distinct biome-
chanical properties of these 2 regions and their potential
impact on clinical practice.
Disclosures
The authors declared no potential conflicts of interest with
respect to the research, authorship, and publication of this
article.
Funding
The authors received no financial support for the research,
authorship, and publication of this article.
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Region I Region II
Parameter Value SE Value SE
A
0
34.86 E-03 3.56 E-03 3.08 E-03 3.04 E-03
A
1
16.84 E-03 4.73E-04 7.74 E-03 3.66E-04
A
2
1.85 E-03 1.94E-05 1.14 E-03 1.36E-05
A
3
2.89E-05 3.25E-07 1.80E-05 2.07E-07
A
4
1.71E-07 2.38E-09 1.06E-07 1.37E-09
A
5
3.68E-10 6.30E-12 2.25E-10 3.28E-12
Adjusted R
2
0.99873 0.99794
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