Aesthetic Plastic Surgery Journal (SCI) 2018: The Inclusion of Orbicularis Oculi Muscle in the SMAS Flap in Asian Facelift: Anatomical Consideration of Orbicularis Muscle and Zygomaticus Major Muscle

 Aesthetic Plastic Surgery (SCI) 2018:
“The Inclusion of Orbicularis Oculi Muscle in the SMAS Flap in Asian Facelift: Anatomical Consideration of Orbicularis Muscle and Zygomaticus Major Muscle”

As there has been limited research on the anatomical boundaries of the orbicularis oculi muscle (OOM), and particularly, the spatial relationship between the OOM and the zygomaticus major muscle (ZMM), they have often been inaccurately represented in anatomical textbooks and visual references. 

In my paper entitled, “The Inclusion of Orbicularis Oculi Muscle (OOM) in the SMAS flap in Asian Facelift: Anatomical Consideration of Orbicularis Muscle and Zygomaticus Major Muscle (ZMM),” mainly focuses on the anatomical structures involved in facelift surgery, specifically for Asian patients, the role and inclusion of the orbicularis oculi muscle in the SMAS flap, as well as its relationship with the zygomaticus major muscle, providing detailed anatomical insights relevant to facelift procedures. 

In this study, I measured the distances from the tragus to both the lateral border of the OOM and the ZMM. The analysis of this data revealed that the lateral border of the OOM lies approximately 10mm lateral to the  ZMM. This finding indicates that the OOM extensively overlaps the ZMM, and that the ZMM cannot be adequately exposed without first dissecting the OOM.

Clinically, it has been suggested that the SMAS layer in the malar (cheekbone) region is thin, fragile, and difficult to secure during surgery. To overcome this, I have incorporated the orbicularis oculi muscle (OOM) into the SMAS flap to create a thicker and more rigid flap. While each surgeon may have their own interpretation of the SMAS layer and facelift techniques, the dissection of the orbicularis oculi muscle has long been utilized by leading experts in the field.

“…The thicker retaining ligaments and skin of the Asian face, as well as its broad, flat midface contour, often require more aggressive methods to achieve such outcomes. However, it is often the case that the SMAS in the malar region is thinly elevated and poorly fixed. 

The authors were able to overcome this challenge by including the OOM with their SMAS elevation to provide a high-quality flap for appropriate and durable tissue resuspension.

The relationship between the muscles in the malar area was unclear, but our careful anatomical study confirmed that the OOM extended laterally beyond the origin of the ZMM by approximately 10 mm and that the OOM must be elevated to identify the deeper ZMM. The authors hope that these anatomical findings would be useful when performing it and aid in understanding the relationship between the muscles in the malar area. 

Because of the small number of patients evaluated in this study, the limited follow-up period, and a general lack of reported data in the Asian literature, further studies are needed to evaluate and refine our approach in this patient population.” 

(Ryu MH, Moon VC, Yin W. The Inclusion of Orbicularis Oculi Muscle in the SMAS Flap in Asian Facelift: Anatomical Consideration of Orbicularis Muscle and Zygomaticus Major Muscle. Aesth Plast Surg 2018;42(2), 471-478)

This study has been published in Aesthetic Plastic Surgery (SCI) — the official journal of the International Society of Aesthetic Plastic Surgery (ISAPS) and a recognized SCI-indexed journal. It was presented and discussed at the 2017 Aesthetic Surgery Symposium of the American Society of Plastic Surgeons (ASPS) and at PRS KOREA 2017, the International Congress of the Korean Society of Plastic and Reconstructive Surgeons. 

In a clinical perspective, this research focuses on the application of the SMAS and the orbicularis oculi muscle (OOM) in facelift surgery. Whilst in the anatomical perspective, it deals with the positional relationship between the orbicularis oculi muscle (OOM) and the zygomaticus major muscle (ZMM).

https://rnwoodplasticsurgery.blogspot.com/2017/03/asps-aesthetica-2017-symposium-new.html  

https://rnwoodplasticsurgery.blogspot.com/2017/11/invited-faculty-in-prs-korea-2017.html 

This paper is also a follow-up to my previous paper that was published in the Aesthetic Surgery Journal (SCI), issued by the American Society for Aesthetic Plastic Surgery (ASAPS) and Oxford University Press. This study emphasizes on the midface and the lower face, taking into account the anatomical characteristics of East Asians. It is significant in that it integrates the historical techniques and theories of renowned experts. Furthermore, it has shown positive outcomes in addressing cheek ptosis following facial contouring or orthognathic (jaw) surgery.

https://rnwoodplasticsurgery.blogspot.com/2014/01/the-surgical-correction-of-crows-feet.html 

https://rnwoodplasticsurgery.blogspot.com/2017/10/plastic-surgery-meeting-2017-in-orlando.html 

In New York, Dr. Aston has employed OOM dissection for over 30 years as part of his FAME technique. Similarly, Dr. Mendelson, who interprets the SMAS as being in the same anatomical plane as the OOM and the platysma muscle, includes both in his SMAS dissection. Dr. Timothy Marten, renowned for his lamellar high SMAS facelift technique, also includes the OOM in the SMAS flap, consistent with my approach.

In his publication (Clinics in Plastic Surgery, 2008, Fig. 25), Dr. Marten refers to the tissue at the anterior portion of the SMAS flap as the "malar fat pad," but based on its anatomical location, color, and structure, it is likely the orbicularis oculi muscle. While there are various theories and techniques in facelift surgery, this method is not a new innovation, but rather a proven and safe approach that has been employed by experts over a long period.

https://rnwoodplasticsurgery.blogspot.com/2017/05/invited-faculty-in-mafac-san-diego-2017.html 

https://rnwoodplasticsurgery.blogspot.com/2012/08/mcps-in-san-francisco-2012.html 

Dr. Stuzin, who is known for the extended SMAS technique, dissects the platysma muscle during SMAS elevation but leaves the orbicularis oculi muscle intact, instead elevating a thin fascial layer above it. However, this method has limitations particularly in the malar region—where the SMAS flap tends to be thin. It is prone to tearing and is difficult to secure firmly. To compensate for these drawbacks, his technique often involves overlapping the flap or creating a thinner skin flap that includes more subcutaneous fat to reinforce the area. Nevertheless, in patients with lean facial anatomy or in revision cases, it may be difficult to achieve a sufficiently thick SMAS flap, potentially leading to suboptimal or unsatisfactory results. In fact, in his 2014 PRS surgical video, the SMAS dissection in the malar area appears too thin, resulting in tearing and a lack of solid fixation—ultimately limiting midface rejuvenation

https://rnwoodplasticsurgery.blogspot.com/2018/05/aesthetic-meeting-2018-in-new-york.html 

As mentioned, this journal aims to clarify the previously confusing surgical anatomy of the malar region and to closely examine a technique that has been safely employed over many years by leading experts in the field. While the data in this study is based on East Asian subjects and may not be easily generalized to other populations, the findings regarding the spatial relationship between the orbicularis oculi muscle and the zygomaticus major muscle highlight an area that warrants further research.

Notably, Dr. Bryan Mendelson shared the following comment on his personal Facebook page in response to this publication:

“…Prior to your publication I was of the belief that the orbicularis lateral extent was the lateral border of the body of the zygoma, which would be about the same distance you measured from z. major, but not measured distance as you provide…”

His remarks underscore the importance of this anatomical clarification and the value of objective, measured data in refining surgical understanding.

The goal of a facelift is to lift and reposition sagging soft tissues to improve facial contour. In achieving this, the processes of tissue dissection, repositioning, and fixation are all critically important. If any one of these components is insufficient, it becomes difficult to achieve satisfactory results. Even with precise dissection and repositioning, the outcome may fall short if fixation is not secure. This is especially true in cases involving facial contour correction or post-orthognathic surgery midface ptosis, where meticulous dissection, repositioning, and fixation of the midface are essential.

Each master surgeon brings different theories and techniques. While it is important to learn from and respect their work, I believe that advancing the field also requires a critical perspective—one that identifies gaps and seeks to improve upon them. Healthy, mature discussion and mutual respect are essential to academic progress. I also welcome critical evaluation of my own work, in the hope that through shared insights and collaborative refinement, we may make a meaningful contribution to the ongoing development of facial surgery. I will continue to strive to contribute to the advancement of facial anatomy and facelift techniques specifically tailored for Asian patients.

Dr. Minhee Ryu, M.D.

RNWOOD Plastic Surgery

Seoul, South Korea

(Source: https://blog.naver.com/rejuvemaster/221227064168 )

Dr. Minhee Ryu is a World-Class FACELIFT Specialist and Global Educator, who is deeply committed to sharing his facial rejuvenation surgery and anatomy expertise. As a lecturer, tutor, and demonstrator, he is invited to deliver DEEP PLANE FACELIFT presentations and perform live surgery and cadaver dissection Demonstrations in more than 15 countries, including Korea, the US, Europe, Singapore, Australia, Japan, and beyond.

Recognized worldwide for his expertise in DEEP PLANE FACELIFT, Dr. Ryu is a Faculty Member at MAFAC since 2016, a guest Faculty Member at Mayo Clinic since 2023, and an Editorial Board Member for the Aesthetic Plastic Surgery Journal (SCI) since 2019. He is an active member of KSPRS, ASPS, ASAPS, and ISAPS. As a global top-tier leader in Facelifts, Dr. Minhee Ryu makes dedicated contributions to academic advancement and surgical education.

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