“TL;DR: The superficial musculoaponeurotic system (SMAS) is a collagen-rich connective tissue layer beneath the skin, situated between superficial and deep facial fat, often containing fat itself, which adds volume and softness to the face. It connects facial muscles to the dermis, enabling facial expressions and influencing skin laxity—loose SMAS leads to sagging, while a tight SMAS promotes firmness. Non-surgical treatments like high-intensity focused ultrasound (HIFU), radiofrequency (RF), and RF microneedling target the SMAS for skin tightening and lifting but carry significant risks. The SMAS varies in depth and thickness across individuals and even within different areas of the same face, making it nearly impossible to target precisely without affecting surrounding or embedded fat tissues. This often results in unintended facial fat loss, burns, lumps, or fibrosis, particularly in areas like the nasolabial fold treated by these energy-based procedures. These treatments rely on high-intensity thermal damage, inducing scarring / deep skin hardening that is presented as skin tightening, but individual tissue sensitivity makes outcomes unpredictable. Pain, often masked by numbing creams, isn’t a reliable gauge of safe energy application, and low-intensity alternatives are ineffective in single sessions, requiring 6-12 sessions for results. Unlike surgical facelifts, which lift skin, fat, and SMAS together without burning, these non-surgical methods risk uncontrolled damage, leading some to report “HIFU ruined my face” or similar outcomes. Safe alternatives target the dermis with 6-12 high-power but non-excessive RF sessions, avoiding the SMAS entirely. These gradual, pain-free, downtime-free treatments stimulate natural tightening without affecting facial fat, unlike 1-2 intense, profitable but hazardous sessions. For those seeking facial fat reduction, gradual, safe RF or ultrasound treatments over multiple sessions are advised to prevent fibrosis, adhesions, or lumps. Focusing solely on the dermis ensures effective, low-risk skin tightening, prioritising safety over quick, risky procedures that may necessitate costly, lengthy corrective treatments.”
Targeting the SMAS for skin tightening with a non-surgical treatment: what a stupid idea
The SMAShing madness of targeting the SMAS and causing facial fat loss and fibrosis
What is the SMAS and how does it affect facial skin tightness and facial fat?
All in all, the SMAS is a collagen-rich connective tissue layer sandwiched between superficial and deep facial fat and contains fat within itself too
Key points about the SMAS
SMAS depth, SMAS thickness and facial fat
The stupidity of trying to tighten facial skin by targeting the fat with HIFU, RF or RF microneedling
If you go for treatments that aim to cause 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?
Moral of the story: how to avoid losing facial fat and/or getting fibrosis with non-surgical treatments
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The SMAShing madness of targeting the SMAS and causing facial fat loss and fibrosis
“Why did I lose facial fat with HIFU / RF microneedling? They told me they would just target the SMAS to “lift” my face.”
This is a more and more common question as everyone who is interested in facial skin tightening and lifting 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 and facial fat?
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…
..[The SMAS] 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.…
Source: https://www.ncbi.nlm.nih.gov/books/NBK519014/
All in all, the SMAS is a collagen-rich connective tissue layer sandwiched between superficial and deep facial fat and contains fat within itself too
So good luck trying to target the SMAS while avoiding facial fat tissues (and therefore facial fat loss) that many ignorant HIFU, RF microneedling and RF practitioners aim.
The only safe HIFU, RF microneedling and RF treatment for skin tightening is one that targets the dermis. Not too superficial to target the epidermis but not too deep either to target the hyped-up SMAS.
Check more on SMAS and facial fat anatomy below and read why it is utterly stupid to target the SMAS, if the client does not want to lose facial fat.
The mid-face fat compartments are classified as superficial and deep. It is very important to distinguish between these two different categories.
The superficial fat compartments are localised between the skin and the plane of the superficial muscular aponeurotic system (SMAS), that consists of a three-dimensional architecture of collagen, elastic, and muscle fibres as well as fat cells.
The fat tissue of the superficial compartments is found WITHIN this fibrotic network.
Beneath the SMAS plane, deep to the muscles of facial expression, we find the deep fat compartments extend to and adhere to the periosteum.
Source: https://www.oatext.com/anatomy-and-aging-of-cheek-fat-compartments.php#Article
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…
The stupidity of trying to tighten facial skin by targeting the fat with HIFU, RF or RF microneedling
Hence the rise in people saying:
”Radiofrequency ruined my face”
“HIFU ruined my face”
“RF microneedling ruined my face”
Sure, not all the above horrific cases are due to targeting the SMAS with extreme intensity HIFU, RF or RF microneedling but many are.
(The rest are due to (the utterly stupid) attitude of using extreme intensity HIFU, RF or RF microneedling for results with 1 or 2 unsafe BUT EXTREMELY PROFITABLE $$$ sessions, as opposed to 6-12 SAFE but unprofitable and laborious deep-acting, high-power radiofrequency sessions.)
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).
If you go for treatments that aim to cause 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 high intensity, painful, so-called “controlled” thermal damage, followed by “controlled” fibrosis, to effect “skin tightening” (‘post-burn scar tissue’, more accurately, which passes off 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 / 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 1-2 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 1-2 “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…
Moral of the story: how to avoid losing facial fat and/or getting fibrosis with non-surgical treatments
The only skin layer to treat for facial skin tightening and lifting if you don’t want to lose fat, is the dermis. Anything else, and you risk losing fat.
And the only way to effect skin tightening is with the stimulating, non-distractive, method (i.e. multiple, safe sessions, not a couple brutal ones). Anything else and you risk damaging/burning the skin and getting fibrosis.
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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.
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Our radiofrequency/ultrasound/LED treatments are comfortable, pain-free, downtime-free, injection-free, 99.5%+ safe and always non-invasive.
(No unsafe and ineffective RF microneedling or HIFU and no safe but ineffective acoustic wave therapy, superficial RF (bipolar/tripolar/multipolar etc), low power RF/cavitation, electrical muscle stimulation, lymphatic massage, cupping, dry brushing and no ridiculous bum bum creams.)
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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