Targeting the SMAS with RF microneedling, HIFU or radiofrequency: what a stupid idea

SMAS, RF microneedling, HIFU, extreme intensity radiofrequency, facial fat loss and fibrosis: the connection

• Stop the SMAS madness!

• What is the SMAS and how does it affect facial skin tightness?

• Key points about the SMAS

• SMAS depth, SMAS thickness and facial fat

• “Radiofrequency / HIFU / RF microneedling ruined my face”

• With treatments that aim for post thermal damage fibrosis all bets are off

• But surgeons target the SMAS…

• But I had HIFU / RF microneedling / radiofrequency that targeted the SMAS and I saw results / didn’t get injured

• What if I do want to reduce facial fat?

• Have a skin tightening treatment in London with the natural skin tightening experts

Stop the SMAS madness!

Everyone interested in facial anti-ageing these days is talking about the SMAS.

Suddenly everyone is an (ignorant) “expert” in the SMAS, just like everyone interested in cellulite or massage suddenly became an (ignorant) “expert” in all things fascia a few years ago.

But what is the SMAS, why is everyone talking about it and why is it not such a great idea to target it non-surgically?

What is the SMAS and how does it affect facial skin tightness?

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“The superficial musculoaponeurotic system, or SMAS, is often described as an organised fibrous network composed of the platysma muscle, parotid fascia, and fibromuscular layer covering the cheek. This system divides the face's deep and superficial adipose tissue and has region-specific morphology. Anatomically, the SMAS lies inferior to the zygomatic arch and superior to the platysma's muscular belly…

…The SMAS connects the facial muscles to the dermis…

…Khawaja et al referred to this musculoaponeurotic network as the "superficial musculoaponeurotic fatty system" (SMAFS) in their study of 800 facelift procedures. The authors found that 6 SMAFS variants existed based on fatty layer composition: membranous, fatty, mixed, island, fleshy, and fibrous.”…

…Type 1 SMAS lies in the region lateral to the nasolabial fold (NLF). Type 2 SMAS is medial to the NLF. These 2 SMAS areas primarily differ in their cellular architecture and underlying structures. Type 1 SMAS overlies the key facial expression muscles and is composed of large fat lobules entwined in a fibrous septal network. This area is relatively loose, enabling mobility of the underlying muscles…

Key points about the SMAS (and the SMAFS)

• The SMAS is a thick connective tissue rich in collagen found deep in the skin where facial muscles stick to (this is what an ‘aponeurosis’ is defined as)

• Through the SMAS facial muscles control facial expressions on the skin

• The SMAS can contribute to skin laxity if it is loose and to skin firmness if it is tight

• As the SMAS quite often contain adipose tissue (fat) also adds volume and softness to the skin (data from 800 facelift procedures), hence its other name of SMAFS, i.e. ‘superficial musculoaponeurotic FATTY system’

• The SMAS laterally to the nasolabial fold (i.e. the SMAS commonly treated by energy procedures) contains fat enveloped in it

SMAS depth, SMAS thickness and facial fat

The above accurate and concise description of the SMAS tells us that:

• There is fatty tissue right ABOVE, INSIDE, and right BELOW the SMAS, i.e. the SMAS is sandwiched by fat and also contains fat itself, especially on the areas treated by energy procedures

• The SMAS does not have the same thickness and it is not found at the same depth, both of which (depth and thickness) varying from person to person and from centimetre to centimetre of each person’s face

Taking these two things together we understand that it is almost impossible:

• To target the SMAS of a specific facial spot with high intensity HIFU, high intensity radiofrequency or high intensity RF microneedling, accurately enough to potentially not lead to facial fat loss

• To target the SMAS of a specific facial spot with the right amount of high intensity HIFU, high intensity radiofrequency or high intensity RF microneedling energy, so that it will not be too much on a thin SMAS (leading to burn/lumps/fibrosis/skin damage) or that will not be too little on a thick SMAS (not dangerous but ineffective, as in this case nothing happens and the treatment is a waste of time and money)

• Given that quite often the SMAS contains fat within itself, even if you target it accurately and with the right amount of energy you could still lose facial fat - not great for the vast majority of people who undergo facial skin tightening procedures

This means that targeting the SMAS with RF microneedling / radiofrequency / HIFU is a wild guess / shot in the dark / disaster waiting to happen.

Of course, not in all cases disaster happens. Quite a few people are happy with the procedure, in the same way quite a few people are happy with betting on the right number on the roulette. The problem lies with those who get burned/lose facial volume with such treatments and then have to spend a fortune to fix it…

“Radiofrequency / HIFU / RF microneedling ruined my face”

Hence the rise in people saying “Radiofrequency / HIFU / RF microneedling ruined my face”.

Because someone was ignorant, arrogant or irresponsible enough to believe that they can accurately target a tissue which varies in thickness and in depth from centimetre to centimetre on the same person’s face - let alone from person to person.

The fact is that no amount of experience or anatomy knowledge can tell you at what depth and how thick the SMAS or its surrounding fat is without constant ultrasonography monitoring - which would painfully slow down already slow procedures and which would require excellent ultrasonography skills (good luck with that with 99% of HIFU / RF microneedling / radiofrequency practitioners).

With treatments that aim for post thermal damage fibrosis all bets are off

Even if accurate assessment of SMAS depth and SMAS thickness can be ensured, we still have the individual variations of tissue sensitivity / tendency to fibrosis from person to person, in response to excessive energy applied by HIFU / RF / RF microneedling.

Pain is not always an accurate signal to assess if excessive energy is applied. Plus pain is largely masked by numbing creams used for those procedures.

On the other hand, light HIFU, light static radiofrequency or light RF microneedling, that do not require numbing cream, are simply ineffective.

This is because these techniques are based on painful “controlled” thermal damage, followed by “controlled” fibrosis, to effect “skin tightening” (‘post-burn scar tissue’, more accurately, which passes as ‘skin tightening’, to the justifiably naive public).

(If you reduce the intensity enough to make those treatments safe and eliminate pain, nothing happens in one session. Pain-free skin tightening treatments roughly require 6-12 sessions to be effective and the above procedures are too painful and expensive for 6-12 sessions to make sense.)

But surgeons target the SMAS…

That’s the most pathetic argument for the use of high intensity HIFU/RF/RF microneedling I have ever heard.

When surgeons perform a face lift, of course they cut and stitch the whole superficial facial structure, consisting of skin, fat and SMAS, all together, to lift the skin. There is no other way.

And, of course, surgeons do not just cut and stitch only the SMAS leaving the skin where it was - the idea is laughable. The accurate thing to say is that surgeons work up to SMAS depth - they don’t work on the SMAS itself alone.

The whole comparison between high intensity radiofrequency/RF microneedling/HIFU and facial surgery is ridiculous. Face lift surgeons do not burn your fat or the SMAS - either in an uncontrolled or in a “controlled” way.

But I had HIFU/RF microneedling/radiofrequency that targeted the SMAS and I saw results and/or didn’t get injured

Good for you, you’re the lucky one:

• Either the treatment was not strong enough to damage facial fat / to cause any burns on your SMAS/other part of skin - in your specific case

• Or it was strong but luckily applied at exactly at the right spots and right intensity; or you did not react negatively to it

• Or the SMAS was not targeted at all, you actually had treatment applied on the dermis and you are happy with the results

• Or your fat tissue is quite resilient (fat tissue can sometimes be very stubborn in different people / different body areas) and it was not affected

Not all people overreact to extreme treatments. And also some people experience results even with low intensities of treatment. Which is great for them.

Some other people, however, are not so lucky. And given that…

• the SMAS cannot be accurately, safely and effectively targeted

• high intensity (i.e. numbing cream-requiring) RF microneedling/HIFU/radiofrequency are inherently unsafe

…we are against those procedures, even though they are 5-10x more profitable than the safe ones (there is more to life than money).

Instead, for facial skin tightening and lifting, we focus specifically on the dermis with 6-12 sessions of high-power (but never excessive) radiofrequency - as opposed to 1-4 extremely intensive and unsafe “miracle procedures”, such as the above.

And of course, we never touch the SMAS - we leave that to surgeons.

The gradual, natural approach may require more sessions but is is safe, pain-free, downtime-free, does not affect facial fat and works by stimulating change, as opposed to causing controlled burns and consequent fibrosis, that can easily be out of control and require years / thousands of £££ of corrective treatments to make right.

What if I do want to reduce facial fat?

Again, for the same reasons mentioned above, it is better to target fat in a gradual, painless, fat loss-stimulating method (i.e. with 12x deep-acting, high-power but not extreme, SAFE RF / ultrasound treatments), than to target it with 1-4 “instant”, painful, UNSAFE, fibrosis-stimulating sessions.

We have the same issue at the clinic with people showing up for help after trying to achieve instant cellulite/fat reduction on the body, only to end up fighting fibrosis, adhesions, lumps and bumps for years to come.

Safety first…

Have a skin tightening treatment in London with the natural skin tightening experts

At LipoTherapeia we have specialised 100% in skin tightening and cellulite reduction for more than two decades and 20,000+ sessions.

This is all we study and practise every day and have researched and tried hands-on all the important skin tightening equipment and their manufacturers.

As strong, deep acting radiofrequency and deep-acting, high-power ultrasound cavitation are the technologies of choice for skin tightening and cellulite reduction, we have invested in the best RF/ultrasound technologies in the world.

Furthermore, over the last two decades we have developed advanced RF and cavitation treatment protocols in order to make the most of our technologies, for maximum results, naturally and safely.

Our radiofrequency/ultrasound treatments are comfortable, pain-free, downtime-free, injection-free, microneedling-free, 99.5%+ safe and always non-invasive.

And our focus is on honest, realistic, science-based treatment, combined with caring, professional service, with a smile.

We will be pleased to see you, assess your cellulite, skin laxity or fibrosis, listen to your story, discuss your case and offer you the best possible treatment.

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