This is “Advance Publication Article”

Review Article Kurume Medical Journal, 68, 53-61, 2021

The Key Structure of the Facial Soft Tissue: The Superficial

Musculoaponeurotic System
KOICHI WATANABE*, AYA HAN*,**, EIKO INOUE*,‡, JOE IWANAGA*,§§, YOKO TABIRA*,
AKIHIRO YAMASHITA*,†, KEISHIRO KIKUCHI*,†, YUTO HAIKATA*,
KUNIMITSU NOOMA* AND TSUYOSHI SAGA§

*Division of Gross and Clinical Anatomy, Department of Anatomy,

**Department of Plastic, Reconstructive, and Maxillofacial Surgery,
†
Department of Orthopedic Surgery Kurume University School of Medicine, Kurume 830-0011,
‡
Jyosui Dermatology Clinic, Fukuoka 810-0022,
§
School of Nursery Kurume University School of Medicine, Kurume 830-0003, Japan,
§§
Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine,
New Orleans 70112, USA

Received 9 December 2020, accepted 17 May 2021

J-STAGE advance publication 17 April 2023

Edited by KENSUKE KIYOKAWA

Summary: The superficial musculoaponeurotic system (SMAS) was advocated by Mitz and Peyronie in 1976.
The concept of this superficial fascia was established by surgical findings of facelift surgery and is familiar to plas-
tic surgeons and anatomists. However, detailed characteristics of this fascia are still not widely known among head
and neck surgeons. Moreover, the SMAS is generally located at the parotid and cheek regions and divides facial fat
into superficial and deep layers. The SMAS connects to the superficial temporal fascia cranially and to the pla-
tysma caudally. The frontal muscle and the peripheral part of the orbicularis oculi are also in the same plane. The
exact expanse of the SMAS in the face is controversial. Some authors claimed that the SMAS exists in the upper
lip, whereas others denied the continuity of the SMAS to the superficial temporal fascia in a histological study.
There are various other opinions regarding SMAS aside from those mentioned above. The concept of the SMAS is
very important for facial soft tissue surgeries because the SMAS is a good surgical landmark to avoid facial nerve
injuries. Therefore, this article summarized SMAS from an anatomical point of view.

Keywords SMAS, superficial musculoaponeurotic system, platysma, superficial temporal fascia, superficial
fascia, retaining ligament, facial nerve

[1], a periodically updated anatomical textbook, has

INTRODUCTION
The superficial musculoaponeurotic system (SMAS)
is a superficial fascia spreading across the entire face.
The concept of this superficial fascia was established
by surgical findings of facelift surgery and is well-
known among plastic surgeons. Aside from plastic
surgeons and anatomists, this fascia is still not widely
known by head and neck surgeons. Gray’s Anatomy
already included a description of the fascia, whereas
most other anatomical textbooks have not. Thus, the
concept of the fascia is spreading and gradually being
recognized. This review aimed to summarize the
SMAS, and to provide suitable resources for head and
neck surgeons to help them perform better surgeries.
History of Smas

Corresponding Author: Koichi Watanabe M.D., Ph.D., Division of Gross and Clinical Anatomy, Department of Anatomy, Kurume University School of
Medicine, 67 Asahi-machi Kurume, Fukuoka 830-0011, Japan. E-mail: koichiwatanabeprs@gmail.com

Abbreviation: SMAS, superficial musculoaponeurotic system.

54 WATANABE ET AL.
SMAS was first described by Mitz and Peyronie in
1976 as a superficial fascia covering the entire face
[2]. This anatomical structure is of particular impor-
tance for facelift surgery. Before SMAS was described,
Skoog had considerably improved the facelift [3]. Be-
fore Skoog, most surgeons only performed facelift
surgery by removing the loosened skin, thereby under-
mining the facial skin, and placating the skin with ten-
sion after excising the abandoned skin. However,
treating only the surface of the skin was not enough to
improve the unevenness of the aging face. Skoog de-
veloped a novel method to smoothen the deeper tis-
sues by creating a superficial fascial flap and remov-
ing the loosening fascia, which was subsequently
responsible for the advent of modern facelift surgery.
Therefore, theoretically, the concept of SMAS may
have originated by proving this operative procedure.
Before Mitz and Peyronie first described the
SMAS [2], the superficial fascia of the face was al-
ready known and the fact that the fascia covered the
entire face had already been advocated; however, the
description of the fascia was unclear. In the 25th edi-
tion of Gray’s Anatomy published in 1949 [4], the
structure of the superficial fascia of the head is de-
scribed differently to the currently known SMAS.
Gray’s Anatomy mentions that the superficial fascia
(tela subcutanea) of the head invests the facial mus-
cles, forms galea aponeurotica under the scalp, is thin-
ner on the forehead and the skin is closely attached to
the frontalis muscle, is composed of subcutaneous
loose areolar tissue superficial on the eyelids, contains
a considerable amount of fat on the cheeks and lips
and is tougher and more fibrous, and is reduced over
the cartilages of the nose and the external ear. These
descriptions show that the superficial fascia of the face
was considered to exist only as a concept. However,
Mits and Peyronie describe that the SMAS exists in
the parotid and cheek areas and divides the subcutane-
ous fat into the superficial (small and enclosed by the
fibrous septa running from the SMAS to the dermis)
and the deep layer (abundant and not divided by fi-
brous septa). Moreover, SMAS continues to the super-
ficial temporal muscle, the orbicularis oculi, and the
frontal muscle superiorly and the platysma inferiorly.
It becomes thinner in the cheek region, but is in the
same plane as the risorius.
Several researchers have attempted to elucidate
the details of the superficial fascia of the face. The
SMAS was investigated in various places in the face,
including the external nose (the nasal SMAS) and the
lip (labial SMAS) [5,6]. Histological studies of SMAS
Kurume Medical Journal Vol. 68, No. 2 2021
have also been performed. Ghassemi et al. claimed
that two histologically different types of SMAS exist
lateral and medial to the nasolabial fold. Type 1 SMAS
is located lateral to the nasolabial fold with relatively
small fibrous septa enclosing lobules of fat cells. Type
2 SMAS is located medial to the nasolabial fold with a
dense collagen–muscle fiber meshwork. Furthermore,
the SMAS in the lower eyelid cranial to the infraorbi-
tal fold and parotid region are proved as histologically
different structures [7,8].
Constitution of SMAS and facial fascia
Although the term SMAS is common in the field
of plastic surgery, the extent of SMAS remains contro-
versial. Mitz and Peyronie described SMAS as the fas-
cia in the parotid and cheek areas. These fasciae divide
the facial fat tissues into superficial and deep fats.
SMAS continues to the superficial temporal fascia and
frontalis muscle superiorly and the platysma inferior-
ly. The peripheral region of the orbicularis oculi and
risorius is in the same plane as SMAS (Fig. 1).
1. SMAS (in a narrow sense; the parotid and cheek
areas)
SMAS is thick and well-defined in the parotid re-
gion. Mitz described the SMAS in the parotid area as
a condensed mesh that is distinct from the fascia of the
parotid gland. Continuing anteriorly to the cheek area,
the SMAS is thinner and difficult to trace by the naked
eye. Many surgeons agree that the SMAS continues to
the platysma, and the SMAS and the superficial layer
of the parotid fascia attach firmly in the parotid gland.
This is also confirmed by an embryological study [9].
However, Jost claimed in a comparative and embryo-
logical study that the fascia covering the parotid gland
superficially and continuing to the platysma is not the
SMAS, but a parotid fascia, which is a part of the deep
fascia in the face [10].
2. SMAS (in a broad sense) including the structures
connecting the SMAS in a narrow sense
The SMAS layer is generally spread across the en-
tire face. Many surgeons reinforced this belief by per-
forming a sub-SMAS dissection during facelift sur-
geries. However, contrary indications are also claimed
by histological and embryological studies. Addition-
ally, Gardetto found that SMAS existed only in the
parotid region [11].
In the temporal region, SMAS is said to continue
to the superficial temporal fascia. However, some au-
thors disagree with this continuation [11-13]. The con-
tinuation of the labial region is also controversial. For
 THE SUPERFICIAL MUSCULOAPONEUROTIC SYSTEM
example, Yousif et al. claimed that the SMAS exists in
the upper lip [14], but some authors denied its exist-
ence in the labial region [11,15].
3. Deep fascia of the face and the relationship with
SMAS
Stuzin described the details of the deep fascia in
the face [16]. The deep temporal fascia continues to
the masseteric fascia in the cheek through the surface
of the periosteum of the zygomatic arch and finally
continues to the investing fascia in the neck. The mas-
seteric fascia continues to the parotid fascia posteri-
orly. This series of fascia is called parotideomasseteric
fascia. Beyond the anterior border of the masseter, the
masseteric fascia continues to the fascia covering the
surface of the buccal fat pad and is located deep with-
in the upper lip elevator muscles. Moreover, the deep
fascia connects to the SMAS in some areas. The re-
taining ligaments connect the deep structures includ-
ing deep fascia and periosteum to the superficial tissue
like the SMAS and the more superficial tissue of the
dermis.
Stuzin classified the retaining ligament into the
following two types: true and false. The true ligament
arises from the periosteum of the facial bone, whereas
the false ligament arises from other structures like
deep fascia [16]. Both types of ligament are attached
to the SMAS and their fibers branch into the dermis.
The zygomatic ligament and the mandibular ligament
are the representative true ligaments; they are located
in the body of the zygomatic bone lateral to the origin
of the zygomatic major and the body of the mandible
anterior to the insertion of the masseter, respectively.
The masseteric ligaments which arise from the mas-
seteric fascia around the anterior border of the masse-
ter are the representative false ligaments. There is a
connection between the SMAS and the deep fascia
aside from the retaining ligament; this sheet-like con-
nection between the two types of fasciae is called ad-
hesion [17]. The representative adhesion is observed
in the lower temporal region. The septum, which con-
nects the SMAS and the deep fascia and creates the
isolated spaces, is also located in the face. The repre-
sentative septum is observed on the temporal line
known as the superior temporal septum.
4. Relationship between the peripheral branches of the
facial nerve
The two elements of the facial nerve include the
motor fibers and the intermediate nerve, which con-
tains special sensory neurons related to taste and the
parasympathetic fibers. The motor fibers of the facial
Kurume Medical Journal Vol. 68, No. 2 2021
55
nerve are distributed to the muscles of the facial ex-
pression. The motor fiber comes out from the stylo-
mastoid foramen and runs in the parotid gland after
branching the posterior auricular nerve and the nerves
to the digastric and stylohyoid muscles. In the parotid
gland, the nerve divides into two branches: temporofa-
cial and cervicofacial. The temporofacial branch rami-
fies into the temporal and the zygomatic branches.
These branches pierce the superior and anterior mar-
gins of the parotid gland, respectively. Moreover, they
distribute to the facial muscles in the forehead and
around the eye, respectively. The cervicofacial branch
ramifies into the buccal, marginal mandibular, and
cervical branches. The buccal branch pierces the ante-
rior margin of the parotid gland and distributes to the
muscles around the mouth. The marginal mandibular
and cervical branches come out from the lower pole of
the parotid gland and distribute to the muscle of the
lower lip and the platysma, respectively. The branches
of the facial nerve run just beneath the SMAS in some
places because the SMAS is closely related to the su-
perficial facial muscles.
Temporal branch
In the temporal region, Pitanguy marked a line,
known as the Pitanguy’s line, that traces the path of
the temporal branch (running between 0.5 cm below
the tragus and 1.5 cm above the lateral end of the eye-
brow) [18]. This line is still popular and useful for sur-
gery because of its simplicity and convenience. How-
ever, the frontal branch is not a single branch but
consists of several branches [9]. Furthermore, the line
is too simple to predict the exact location of the facial
nerve, and does not include information related to the
layer of the nerve. The temporal branch runs on the
periosteum of the zygomatic arch after emerging from
the parotid gland. The subgaleal plane, which is a lay-
er consisting of loose connective tissue beneath the
superficial temporal fascia and part of the SMAS, runs
above the zygomatic arch [19]. Cori et al. stated that a
transition zone of the temporal branch from the sub-
galeal plane beneath the superficial temporal fascia
was located in an area that is 1.5–3.0 cm superior to
the zygomatic arch and 0.9–1.4 cm lateral to the lat-
eral orbital rim [20]. The temporal branch finally
reaches and enters into the lower third of the muscle.
The temporal branch running closely beneath the su-
perficial temporal fascia is appropriate because the
superficial temporal fascia consists of some remnant
facial muscle including temporoparietal and superior
auricular muscles.
56 WATANABE ET AL.
Zygomatic branch
Typically, there are two to six branches of the zy-
gomatic nerve [9]. The upper zygomatic branches pass
superior to the zygomaticus major and enter the supe-
rior part of the orbicularis oculi. The lower zygomatic
branches pass beneath the zygomaticus major and en-
ter the inferior part of the orbicularis oculi muscle
[21].
Buccal branch
There are two to five buccal branches and they of-
ten connect with the zygomatic or marginal mandibu-
lar branches [9]. Saylum stated that all the buccal
branches run inferior to the line connecting the tragus
and nasal ala [22]. They run within the masseteric fas-
cia and on the surface of the buccal fat pad anterior to
the masseter. Moreover, they can be easily confirmed
during a sub-SMAS dissection.
Marginal mandibular and cervical branches
The cervicofacial nerve trunk emerges from the
lower pole of the parotid gland and runs through the
masseteric fascia and the investing fascia of the neck,
which are the serious of continuous fasciae of the deep
fascia of the face. Saeed reported that the bifurcation
of the cervical and marginal mandibular branches is
located approximately 1 cm beneath the mandibular
angle on the line perpendicular to the line connecting
the mastoid process and the mentum [23].
The marginal mandibular nerve runs anteriorly
and crosses the facial artery and vein at the mandibu-
lar border and enters the depressor anguli oris. This
nerve has two to four branches that are proximal to the
point where the facial artery and vein cross over each
other. The cervical branch usually descends and enters
the undersurface of the superior-lateral third of the
platysma muscle [9].
Embryological consideration of SMAS
The embryological development of the SMAS re-
mains debatable. This may be attributed to the contro-
versial theory of SMAS derived from the clinical ex-
periences of the dissection layer of the face and the
constitution of the SMAS. However, it is undoubtable
that the SMAS relates to the superficial facial mus-
cles. Gasser clearly described the embryological de-
velopment of the facial muscles [24]. The facial mus-
cle primordium appears in the mesenchyme of the
second branchial arch in an embryo with a crown–
rump length of 10.5 mm. Through cellular condensa-
tion, each lamina extends by 18 mm in the following
directions: occipital lamina, caudally; cervical lamina,
Kurume Medical Journal Vol. 68, No. 2 2021
caudally; mandibular lamina, mandibular arch region;
and temporal lamina, dorsally. Subsequently, two ad-
ditional structures, the infraorbital lamina and the oc-
cipital platysma, extend from the mesenchyme in em-
bryos with a crown–rump length of 20–23 mm. These
laminae eventually develop to become the facial mus-
cles. The occipital lamina becomes the facial muscles
in the occipital region including the occipital, posteri-
or auricular, and transverses nuchae muscles. The cer-
vical lamina becomes the cervical part of the platys-
ma. The mandibular lamina becomes the mandibular
part of the platysma; depressor labii inferioris, menta-
lis, risorius; and depressor anguli oris. Moreover, it
also becomes the inferior part of the orbicularis oris
muscles. The temporal lamina becomes superior au-
ricular muscle, which is usually considered to be part
of the superficial temporal fascia. The infraorbital
lamina becomes the upper lip elevator muscles includ-
ing the zygomaticus major and minor, the levator labii
superioris, the levator labii superioris alaeque nasi,
and the superior part of the orbicularis oris muscles.
The occipital platysma becomes the occipital part of
the platysma (Fig. 2). Additionally, Zigiotti et al. in-
vestigated the facial tissues of the human fetuses and
concluded that the SMAS on the parotid gland contin-
ued to the platysma [25]. They also concluded that a
proper parotid fascia, which was a part of the deep
fascia and said to wrap the parotid gland with coher-
ence to the SMAS, does not exist. Cuadra-Blanco et
al., in their investigation of human fetuses, concluded
that the SMAS arose from the mandibular extension of
the cervical lamina covering the upper part of the pa-
rotid region [13]. In addition, the SMAS continued to
the platysma but did not continue to the superficial
temporal fascia and labial region. Each lamina that de-
velops to the facial muscles does not connect to the
SMAS layer embryologically.
Gross anatomical findings of SMAS
In the usual series of gross anatomy dissection, a
face is dissected from the surface to the deep layer.
The skin is peeled and the subcutaneous tissue is ob-
served, and the subcutaneous tissue is then removed
and the superficial fascia is examined. Observing the
SMAS in this kind of dissection is very difficult, and
is impossible in the cheek region (Fig. 1). Mitz also
commented that the SMAS is thin and followed only
by microscopy. Thus, the horizontal and coronal sec-
tions of the facial tissue are created and the SMAS and
surrounding tissues are observed.
Observation of the horizontal sections of the face
 THE SUPERFICIAL MUSCULOAPONEUROTIC SYSTEM
In all specimens, the tissues constituting the
SMAS, the SMAS in the parotid region, the platysma,
the superficial temporal fascia, the frontal muscle, and
the orbicularis oculi can be observed. The SMAS is
not a thick sheet-like membrane in the cheek region,
but it can be observed as the border between the super-
ficial fat and deep tissue including facial muscles and
deep fat (Fig. 3).
Observation of the coronal section of the face
Similar to the series in the horizontal sections, the
tissues constituting the SMAS can be observed in all
specimens. The continuity of the SMAS to the super-
ficial temporal fascia and the platysma can be ob-
served especially in the coronal section (Fig. 4).
Histological findings of SMAS
Similar to the results of the most recent anatomy
studies, histological observation reveals that SMAS
can clearly be visualized in the parotid region. How-
ever, it cannot be followed in the cheek region (Figure
5a, b, c). The SMAS is observed only in the border
between the superficial and the deep fat tissues. In the
frontal section in the parotid region, the fasciae arising
from the capsules covering each lobule of the parotid
gland extend cranially to become the superficial tem-
poral fascia. The fascia gradually merge into one to-
ward the cranial region (Figure 5d).
CONCLUSION
There are some confliciting opinions as regards
the continuity of the SMAS. Each structure constitut-
ing the SMAS may have a different embryological
origin. The continuity of SMAS, spreading across the
entire face as a superficial fascia, cannot be micro-
scopically proved. However, SMAS can be followed
with the naked eye in the gross anatomical sections.
Furthermore, the concept of SMAS is extremely use-
ful in facial operation. Appropriate SMAS traction in-
creases the effect of facelift surgery. The appropriate
layer dissection of the facial soft tissue can avoid fa-
cial nerve damage and skin flap necrosis due to poor
blood flow. The knowledge of SMAS is essential not
only for plastic surgeons but also for head and neck
surgeons and other clinicians treating the face.
CONFLICT OF INTEREST: The authors declare no conflict
of interest concerning this study.
ACKNOWLEDGMENT: The authors would like to thank the
individuals who donated their bodies for medical research and
education. We thank Edanz Group (https://en-author-services.
Kurume Medical Journal Vol. 68, No. 2 2021
57
edanz.com/ac) for editing a draft of this manuscript.
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 THE SUPERFICIAL MUSCULOAPONEUROTIC SYSTEM 59

Fig. 1. An overall view of the SMAS. This is a dissection picture of the left hemi-
face. The skin and the superficial fat were removed and the SMAS layer was
exposed. The SMAS is seen on the parotid region as a whitish fibrous sheet.
Some fat exists on the SMAS because the SMAS is strongly connected to the
subcutaneous fat. Similar to the SMAS in the parotid region, some fat tissues
adhere to the superficial temporal fascia and platysma. In the cheek region, the
SMAS cannot be followed via gross anatomical dissection. Thus, the deep fat and
facial muscles beneath the SMAS including zygomatic major were exposed. DAO
depressor anguli oris, DF deep fat, DLI depressor labii inferioris, FM frontal
muscle, Mo modiolas, OOc orbicularis oculi, OOr orbicularis oris, SMAS superfi-
cial musculoaponeurotic system, STF superficial temporal fascia, ZMa zygomati-
cus major.

Fig. 2. Embryological development of the facial muscle and the SMAS. This is a
modified figure based on the article by Gasser [24]

Kurume Medical Journal Vol. 68, No. 2 2021

60 WATANABE ET AL.

a b
Fig. 3. Horizontal section of the left cheek region.
a: The area where the tissue was sampled. b: Sampled tissue.
This is a horizontal section from the cheek below the ear lobe to the upper lip. The SMAS can be followed
superficially to the parotid gland, the masseteric fascia, the zygomatics major, and the orbicularis oris. The
SMAS is a thick membrane on the parotid gland and the masseteric fascia. It can be traced as a border of
facial muscles and the malar fat on the cheek region. BF buccal fat pad, FA facial artery, FV facial vein, LLS
levator labii superioris, LLSAN levator labii superioris alaeque nasi, MA masseter, MF malar fat, OOr orbicu-
laris oris, PG parotid gland, ZMa zygomaticus major. Black arrowheads SMAS

b
Fig. 4. Coronal section of the right face
a: The area where the tissue was sampled. b: Sampled tissue.
The SMAS can be observed as the superficial temporal fascia in the temporal region, the orbicularis oculi in the
lateral orbital and the zygomatic regions, and the border between the malar fat and the zygomatic major in the
cheek region. BA buccinator, BF buccal fat, IC inferior concha, IO inferior oblique, IR inferior rectus, LR lateral
rectus, MC middle concha, MF malar fat, MR medial rectus, MS maxillary sinus, PD parotid duct, SO superior
oblique, SR superior rectus, STF superficial temporal fascia, ZB zygomatic body, ZMa zygomaticus major.

Kurume Medical Journal Vol. 68, No. 2 2021

 THE SUPERFICIAL MUSCULOAPONEUROTIC SYSTEM 61

Fig. 5. Histological findings of the SMAS (Masson’s tri-

chrome staining). a: Horizontal section of the upper lip. The
orbicularis oris connects firmly to the dermis without any fat
tissue. However, it is unclear whether the SMAS exists in the
upper lip. b: Horizontal section of the cheek region. The
SMAS cannot be observed as a thin fibrous layer, but the two
kinds of facial fats, superficial and deep fats, can be
observed. The border of these two kinds of fat can then be d
presumed to be the SMAS (black arrow heads). c: Horizontal
section of the parotid region. The parotid gland is on the masseter and is covered by the deep and parotid masseteric fascia
from the superficial and deep sides, respectively. The SMAS can be observed superficially to the parotid masseteric fascia on
the parotid gland. d: The frontal section of the temporal region. The deep temporal fascia consists of two layers on the caudal
side. These two layers adhere and become one on the cranial side. The superficial temporal fascia, which is a part of the
SMAS, is superficial to the deep temporal fascia and seems to consist of some thin fibrous layers including thin muscle fibers
and a blood vessel.
BF buccal fat pad, Bu buccinators, DTF deep temporal fascia, D-DTF deep layer of the deep temporal fascia, LAO levator
anguli oris, Ma masseter, MF malar fat pad, OOr orbicularis oris, PG parotid gland, PMF parotid masseteric fascia, S-DTF
superficial layer of the deep temporal fascia, SMAS superficial musculoaponeurotic system, STF superficial temporal fascia,
TM temporal muscle, ZMa zygomaticus major.

Kurume Medical Journal Vol. 68, No. 2 2021